GIFT   OF 


OUTLINES  OF 

GENERAL  AND  SURGICAL 
NURSING 


BY 

WINIFRED  FREDERICK  LINDSAY 

Superintendent  of  the  Training  School  for  Nurses 

Of  the  Paradise  Valley  Sanitarium 

National  City,  Cal. 


LOMA  LINDA,  CAL. 

THE  COLLEGE  PRESS 

1912 


Copyright,  1912,  by  The  College  Press 
Loma  Linda,  Cal. 


DEDICATED  TO  MY  PUPILS 

AT   THE 

PARADISE  VALLEY  SANITARIUM  TRAINING  SCHOOL 

FOR 
MISSIONARY  NURSES 


PREFACE 

No  ATTEMPT  has  been  made  to  present  in  this  little  book, 
an  exhaustive  series  of  outlines,  but  to  briefly  and  concisely  give 
the  essentials,  thus  firmly  impressing  the  main  principles  or 
skeleton,  as  it  were,  of  the  various  subjects.  These  should  be 
elaborated  by  the  instructor. 

Thanks  are  due  Dr.  George  Knapp  Abbott  and  Dr.  Julia  A. 
White  of  Loma  Linda  for  their  many  valuable  suggestions  and 
criticisms.  Also  to  Dr.  Risley  of  Loma  Linda  is  extended  ap- 
preciation for  the  chapter  on  ' '  Poisons. ' ' 

W.  F.  L. 
NATIONAL  CITY 
March,  1912 


CONTENTS 

PART  I 
General  Nursing 

CLINICAL  CONDITIONS  AND  RECORDS.  Body  Temperature,  Pulse,  Respira- 
tion, Bedside  Records.  1 — 11 

THE  SICK  ROOM.     Beds  and  Bed  Making,  Personal  care  of  Patient..  12— 20 

CLINICAL  PROCEDURES.  Lavage,  Test  Breakfast,  Nasal  Douche,  Aural 
Douche,  Hypodermic  Injections,  Catheterization,  Nasal  Feeding,  Nutrient 
Enema,  Poultices,  Diet,  Administration  of  Medicines,  Examinations,  Care 
of  the  Dead "_ 21—40 

SPECIAL  CONDITIONS  AND  EMERGENCIES.  General  Care  of  Infectious 
Cases,  Bed  Sores,  Common  Emergencies,  Poisons 41 — 54 

PART  II 
Surgical  Nursing 

THE  PATIENT.     Preparation  of  Patient's  Room,  Preparation  of  Patient. 
55—75 

THE  OPERATING  ROOM.  Technique  of  Tables,  Duties  of  Staff,  Hand  Dis- 
infection, Sterilizing  Room,  Methods  of  Sterilization,  Suggestive  Operative 
Record,  Preparation  for  Operation  in  Private  Home,  Anesthetics  and  Anes- 
thesia.   ___76— 89 

SURGICAL  AFTER  TREATMENT.  Major  Operations,  Surgical  Complica- 
tions, Special  Procedures  in  Surgical  Nursing. 

ACCIDENTS  AND  MINOR  SURGERY.  Wounds,  Burns,  Boils,  Ulcers  and 
Abscesses,  Hemorrhages,  Sprains,  Fractures.--  __90 — 100 


PART  III 
Solutions 

CHEMICALS  IN  COMMON  USE.  Corrosive  Sublimate,  Carbolic  Acid,  Lysol, 
Creolin,  Formaldehyde,  Potassium  Permanganate,  Boracic  Acid,  Oxalic 
Acid,  Salt,  Alum,  Alcohol,  Peroxide  of  Hydrogen,  Sodium  Bicarbonate, 
Chloride  of  Lime,  lodoform,  Argyrol. 101 — 105 

THE  METRIC  SYSTEM - 106 

PREPARATION  OF  SOLUTIONS.  Coal  Tar  Products,  Formaldehyde,  Bichlor- 
ide of  Mercury,  Potassium  Permanganate,  Boracic  Acid,  Salt,  Cocain. 

.  107—114 


PART  I 
GENERAL    NURSING 

CLINICAL  CONDITIONS  AND  RECORDS 

Body  Temperature 

The  average  normal  temperature  of  the  body  taken  by 
mouth  is  98.6°  F.,  but  under  certain  conditions  may  range  be- 
tween 97.5°  and  99.5°  and  still  be  considered  normal.  A  tem- 
perature above  or  below  these  points  is  abnormal. 

The  normal  variations  may  be  due  to  various  causes,  viz,— 

1.  Part  of  body  in  which  the  temperature  is  taken:    Axilla, 
about  1°  F.  lower  than  by  mouth.     Rectum,  about  1°  F.  higher 
than  by  mouth. 

2.  The  time  of  day.    In  a  .healty  adult  the  temperature 
reaches  its  highest  point  between  5  and  8  P.  M.,  and  is  at  its  low- 
est point  from  2—6  A.  M.      In  young  children  and  the  aged  the 
variations  are  greater  than  in  adults. 

3.  General  and  local  causes,  as,— 

a.  Age.     In  infancy  the  temperature  is  about  1°  F.  higher 
than  in  adults. 

b.  Highly  seasoned,  stimulating  foods. 

c.  Profuse  perspiration. 

d.  Exercise. 

e.  Water  drinking. 

f.  Fasting. 

g.  Emotion. 

The  instrument  for  registering  the  bodily  heat  is  called  a 
clinical  thermometer.  Do  not  fail  to  secure  a  good  and  reliable 
thermometer.  The  best  way  to  test  a  thermometer  is  to  place 
it  along  with  one  of  known  accuracy  at  the  same  moment,  in 
the  mouth  or  rectum.  As  thermometers  change  with  age  they 
should  be  tested  frequently. 


NURSING 

HOW  TO  TAKE  THE  TEMPERATURE 

1.  Mouth:— 

a.  Before  using,  the  mercury  must  be  shaken  down  to  a  point 
2°  or  3°  below  the  normal. 

b.  Rinse  with  clean,  cold  water. 

c.  See  that  the  patient  has  not  taken  water  or  food  within 
20  minutes,  as  this  causes  quite  a  variation. 

d.  Place  the  thermometer  under  the  tongue  from  3 — 5  min- 
utes, the  time  depending  upon  the  kind  of  thermometer  used. 

e.  Do  not  allow  the  patient  to  talk  or  open  the  mouth. 

f.  Remove,   record,   and  wipe  with  a  piece  of  cotton  wet  in 
water,  then  disinfect. 

g.  It  is  not  safe  to  take  the  temperature  of  children  or  un- 
conscious persons  by  mouth  as  they  are  liable  to  bite  the  bulb 
and  swallow  the  mercury. 

2.  Axilla: — 

a.  Remove  clothing  from  under  the  arm  and  dry  the  skin. 

b.  Place  the  bulb  between  folds  of  the  skin  of  the  armpit. 

c.  Bend  the  elbow,    so  that  the  hand  touches  the  opposite 
shoulder.     Leave  in  place  from  7—10  minutes. 

d.  Remove,  record,  and  disinfect. 

3.  Rectum:— 

a.  Do  not  use  the  same  thermometer   for   the   mouth   and 
rectum. 

b.  Oil  the  bulb  and  insert  about  1J  inches. 

c.  Leave  in  place  5  minutes. 

d.  Remove,  record,  and  disinfect. 

CLASSIFICATION  OF  TEMPERATURE 

Temperature  of  collapse  _ .  _  94°— 96°  F. 

Subnormal  tempera ture__  96°— 98°  F. 

Normal  98.6°  with  variations 

Subf  ebrile '. '.  99. 5°-100. 5°  F. 

Fever  of  moderate  degree  __  100.5°— 103°  F. 

High  fever.  103°-105°  F. 

Hyperpyrexia  _  Above  105°  F. 

A  body  temperature  below  95°  or  above  109°  F.,  if  it  per- 
sists for  any  length  of  time,  is  likely  to  be  followed  by  death. 

The  Fahrenheit  scale  is  the  one  principally  used  in  America 
and  England,  but  on  the  continent  of  Europe  the  Centigrade 


PULSE  3 

and  Reaumur  scales  are  generally  used.    To  convert  Fahrenheit 
into  Centigrade,  subtract  32,  multiply  by  5,   and  divide  by  9. 

Example:— 

104°  F.-32°=72°  F. 

72°  F.X5/9=40°C. 

To  convert  Centigrade  into  Fahrenheit,  multiply  by  9,  di- 
vide by  5,  and  add  32  to  the  result. 

Fever  (pyrexia)  is  an  elevation  of  bodily  temperature. 

1.  Continuous.     The  temperature  is  uniformly  above  the 
normal  line,  with  but  slight  variations.     Example:  pneumonia. 

2.  Remittent.     The  temperature  rises  and  falls,  although  it 
never  reaches  the  normal  line.     Example:  typhoid. 

3.  Intermittent.     A  high   temperature  which  at  intervals 
drops  to  the  normal  line,  or  even  below  it.     Example:  tertian 
malarial  fever. 

A  febrile  temperature  may  fall  by  crisis  or  lysis. 

a.  Crisis.     Sudden  drop  to  or  below  normal  (pneumonia). 

b.  Lysis.     Gradual  decline  to  (or  below)  normal  (typhoid). 
As  a  general  rule  the  temperature  becomes  subnormal  for 

several  days  after  a  fever. 

ITEMS  TO  BE  OBSERVED  BY  THE  NURSE 

1.  A  sudden  change  in  temperature,   generally  indicates 
some  complication  and  should  be  reported  to  the  physician  at 
once. 

2.  Temperatures  should  be  recorded  neatly  and  accurately. 
If  you  have  any  reason  to  doubt  the  accuracy  place  after  the 
record  a  (?). 

3.  Keep  thermometers  either  in  their  cases  with  some  cot- 
ton at  the  bottom,  or  in  a  glass  of  disinfectant  solution  with 
cotton  at  the  bottom. 

4.  Thermometer  disinfectants:  Pure  carbolic  acid,  95%  al- 
cohol, formalin,  lysol. 

Pulse 

Every  contraction  of  the  heart  forces  the  blood  into  the 
arteries,  causing  a  distension  of  the  arterial  walls.  It  is  this 
distension  at  regular  intervals  corresponding  to  the  contraction 
of  the  heart  that  is  known  as  the  pulse. 


4  GENERAL  NURSING 

Systole.  A  term  used  to  designate  the  contraction  of  the 
heart. 

Diastole.  The  interval  between  the  contractions,  during 
which  the  ventricles  are  filling  with  blood. 

NORMAL  PULSE 

Men_                        60 —  70  beats  per  minute 

Women__  65-    80  "       " 
Children 

New-born  .  .  120—140  " 

1st  year  _  100—120  " 

2nd    "  90—115  "       " 

3rd     "  80—110  "       " 

7th     "  72—  90  "       " 

HOW  TO  TAKE  THE  PULSE 

Place  two  or  three  fingers  (never  the  thumb)  upon  the 
radial  artery  and  count  carefully  for  one  minute.  When  one 
becomes  accustomed  to  counting  the  pulse,  notice  the  number 
of  beats  for  1/2  minute  and  then  multiply  by  two.  One  can  also 
count  the  pulse  easily  over  the  temporal  artery  and  the  carotid 
artery.  When  taking  the  pulse  the  patient  should  be  either 
sitting  or  lying— never  standing— and  should  have  been  quiet 
for  a  few  minutes  preceding. 

THINGS   WHICH   QUICKEN   THE   PULSE 

1.  Exercise. 

2.  Change  of  position. 

3.  Food. 

4.  Emotion. 

5.  Hot  baths. 

6.  Certain  diseases  as  exophthalmic  goiter — in   fever  the 
pulse  rate  increases  about  ten  beats  for  every  degree  of  rise  in 
temperature. 

7.  Certain  drugs. 

THINGS  WHICH   RETARD   THE   PULSE 

1.  Rest. 

2.  Reclining  position. 

3.  Fasting. 

4.  Cold  to  the  heart. 


PULSE  5 

5.  Certain  disease  conditions  as  jaundice  and  brain  tumor. 

6.  Certain  drugs. 

7.  A  large  amount  of  fluid  introduced  into  the  system. 
The  three  general  attributes  of  the  pulse  are  time,  tension, 

and  rhythm. 

1.  Time  —  normal,  fast,  slow.     The  pulse  is  faster  in  child- 
ren than  in  adults,   and  in  women  than  in  men.      SO— 110  fre- 
quent.     110—140  rapid.     140  and  above  very  rapid  or  running. 

2.  Tension — normal,  high,  low.     A  high  tension  pulse  is  a 
hard,  noncompressible  pulse.    In  hardening  of  the  arteries  (ar- 
terio-sclerosis)  the  artery  may  be  rolled  under  the  finger  like  a 
cord.     A  low  tension  pulse  is  soft  and  easily  compressible. 

3.  Rhythm,     (a)    Irregular.     The  beats  differ  in  length, 
force,  and  character,     (b)  Intermittent.     The  heart  baats  reg- 
ularly for  a  time,  then  one  beat  is  so  weak  as  not  to  be  per- 
ceptible at  the  wrist,  and  it  appears  as  if  the  beat  were  lost;  or 
the  beat  may  actually  be  skipped.     The  rhythm  is  otherwise 
regular. 

TERMS  USED  TO  DENOTE  CHARACTER  OF  PULSE 

1.  Dicrotic.     A  secondary  wave  in  the  blood  current  pro- 
duced by  closure  of  the  aortic  valves.     Less  forcible  than  first 
pulse  wave,   but  sometimes  resembles  it  so  closely  as  to  be 
counted  as  an  individual  beat.     The  error  becomes  apparent  by 
holding  one  hand  on  the  wrist  and  the  other  over  the  heart. 
This   type  of  pulse  is  found  frequently  in  the  acute  fevers, 
particularly  in  typhoid  fever. 

2.  Water-hammer.     Cause— aortic  regurgitation,  i.  e.,  the 
aortic  valves  are  incompetent  to  close  the  opening  into  the  aorta 
so  that  the  pressure  is  not  sustained.    The  artery  suddenly  and 
entirely  collapses  after  each  beat. 

3.  The  following  terms  are  self-explanatory  :    bounding, 
thready,   wiry.     A  bounding  pulse  is  almost  always  found  in 
blood-poisoning  (septicemia). 

A  thready  pulse  indicates  extreme  weakness  of  the  heart 
or  collapse. 

The  wiry  pulse  is  present  in  arterio-sclerosis. 
The  character  of  the  pulse  depends  upon,— 
1.  Action  of  the  heart. 


6  GENERAL  NURSING 

2.  Condition  of  the  arteries  and  capillaries. 

3.  Amount  of  blood  in  the  vascular  system. 

The  instrument  for  recording  the  pulse  tracing  is  known 
as  a  sphygmograph. 

The  character  of  the  pulse  reveals  much  to  the  intelligent 
nurse.  A  good  nurse  will  improve  every  opportunity  to  famil- 
iarize herself  with  the  normal  pulse  and  the  variations  from 
the  normal. 

Respiration 

Rate  in  adult,  18  per  minute. 

Rate  in  children.  Infants,  30-35.  At  5th  year,  20—25. 
At  8th  year,  same  as  adult. 

NORMAL  RATIO  OF  TEMPERATURE,    PULSE,    AND  RESPIRATION 

There  are  four  beats  of  the  heart  to  one  respiration.  As  a 
rule,  every  degree  of  elevation  in  temperature  is  accompanied 
by  an  increase  of  ten  heart  beats. 

Respiration  consists  of,  — 

1.  Inspiration.     The  act  of  taking  air  into  the  lungs. 

2.  Expiration.     The  act  of  expelling  air  from  the  lungs. 
Since  one  expiration  does  not  entirely  empty  the  lungs, 

there  is  always  some  air  in  them  which  is  called  residual  air. 
The  current  which  is  continually  passing  in  and  out  of  the 
lungs  is  called  tidal  air. 

In  counting  the  respiration  one  should  note,  - 

1.  Frequency. 

2.  Regular  or  irregular. 

3.  Difficult  or  easy. 

4.  Noisy  or  quiet. 

5.  Deep  or  shallow. 

6.  Whether  chest  expands  alike  on  both  sides. 

7.  Abdominal  or  thoracic  type. 

The  various  types  of  respiration  are,  — 

1.  Cheyne- Stokes'.  This  consists  in  an  increase  in  the  fre- 
quency and  force  of  respiration  up  to  a  certain  point,  and  then 
a  gradual  decrease  until  the  movements  entirely  cease  for  a 
short  time,  then  the  whole  procedure  is  repeated.  This  type 
may  be  found  in  certain  diseases  of  the  heart  and  kidneys. 


BEDSIDE  RECORDS  7 

2.  Stertorous.     A  loud  snoring  sound  with  each  inspiration. 

3.  Dyspnoea.     Where  the  breathing  is  so  difficult  that  the 
patient  can  not  lie  with  the  head  low. 

4.  Orthopncea.     Where  the  breathing  is  so  difficult  that  the 
patient  assumes  the  upright  position. 

5  Mouth  Breathing.  Common  in  children  who  have  chronic 
congestion  of  the  nasal  passages,  adenoids,  and  enlarged  tonsils. 

The  ear  should  be  trained  to  detect  differences  in  breath- 
ing, so  that  even  in  the  dark,  these  may  be  noticed. 

In  disease  there  are  marked  variations  in  the  character  of 
the  respiration. 

1.  Narcotic  poisoning,  shock,  collapse— slow  and  shallow. 

2.  Pleurisy,  peritonitis— restrained. 

3.  Cerebral  hemor rage— the  cheeks   are   puffed   out  with 
each  breath. 

4.  Peritonitis,  pneumonia — very  rapid,  40 — 50  per  minute. 
This  is  a  very  grave  symptom. 

In  taking  the  respiration  one  must  not  allow  the  patient  to 
be  aware  of  it,  for  he  will  unconsciously  control  it.  After  tak^ 
ing  the  pulse  leave  the  fingers  on  the  wrist  and  count  the  res1 
pirations  while  seeming  to  count  the  pulse. 

Bedside  Records 

A  bedside  record  should  be  a  complete  picture  of  the  con- 
dition of  the  patient.  Its  object  is  to  enable  the  physician  to 
gain  accurate  information  in  regard  to  the  state  of  the  patient, 
and  to  facilitate  a  comparison  of  the  condition  from  day  to  day. 

Neatness,  accuracy,  and  condensation  should  be  observed 
in  making  out  charts.  Enter  the  items  that  have  a  bearing  on 
the  case.  Do  not  record  non-essentials.  Be  quick  to  observe 
symptoms.  These  are  classified  as, — subjective — those  things 
observed  by  the  patient;  objective— those  things  that  are  ob- 
served by  others. 

In  charting,  the  following  abbreviations  are  much  used, 
and  should  be  memorized  by  the  nurse:  — 


GENERAL  NURSING 


aa— equal  parts  of  each, 
ad. — up  to,  to  amount  to. 
ad.  lib. — as  much  as  desired, 
alt.  dieb.  —  every  other  day. 
alt.  hor. — every  other  hour, 
alt.  noc. — every  other  night. 

a.  c. — before  meals. 
Aq. — water. 

Aq.  dest,  —  distilled  water. 
Aq.  pur. — pure  water. 

b.  i.  d. — twice  daily. 
C.— gallon. 

c.  c.— cubic  centimeter. 
Decub. — the  lying  position. 
Dil.  —dilute. 

Div.  —  divide. 
5 — dram. 
Emp. — plaster. 
En. — enema. 
Garg.  —  a  gargle, 
Gr. — grain. 
Gm.  -  gram. 
Gtt.—  a  drop. 
Inf. — infusion. 
Hg.  —mercury. 
Inject. — an  injection. 
lb.— a  pound. 
L.- liter. 
Liq.  -  liquor. 
Lot. —a  lotion. 
M. — mix. 
Mist. —mixture. 


N.— night. 
No. — number. 

0.  — a  pint. 
01. -oil. 

01.  oliv.  —  olive  oil. 
Ov.  —  an  egg. 

0.  M.— every  morning. 

p.  c. — after  meals. 

p.  r.  n. — as  occassion  arises  or 

when  necessary, 
pulv. — a  powder, 
q.  s.— a  sufficient  quantity, 
qt.— quart. 
4.— take. 
S.  or  Sig. — write,  i.  e.,  give  the 

following  directions. 
Sol. — solution. 
Sp.  gr. — specific  gravity. 
ss. —  a  half. 
Spr. — spirit. 
Syr. — syrup. 

T.  i.  d. — three  times  a  day. 
T.  —  tincture. 
Ung.  —  ointment. 
5. — ounce, 
q. — every. 

q.  i.  d.  — four  times  daily, 
q.  1.  h.— every  hour, 
q.  2.  h. — every  2  hours, 
q.  3.  h.— every  3  hours, 
q.  4.  h.— every  4  hours. 
j.—  one. 


THE  FOLLOWING  ITEMS  SHOULD  BE  RECORDED 

1.  Note  and  record  the  temperature,  pulse  and  respiration. 

2.  Defecations:— 

a.  Amount— large,  medium,  small. 

b.  Color — brown,  yellow,  clay,  green,  black,  tarry. 

c.  Consistency— scybala,  solid,  semi-solid,  liquid,  watery. 

d.  Remarks.     Mucus,  pus,  blood,    stones,    undigested   food, 
worms,  odor,  flatus,  tenesmus. 

3.  Urine:— 

a.  Quantity. 

b.  Color. 

c.  Remarks.     Turbidity,  sediment,  blood,  odor,  tenesmus,  re- 


BEDSIDE  RECORDS  9 

tention,    suppression,    constant  dribbling   (incontinence).     All 
abnormal  discharges  must  be  reported  and  described. 

4.  Skin:— 

a.  Note  condition  of  the  skin  as  to  color,  rash,  desquamation, 
marks,  swellings,  whether  hot,  dry,  or  moist,  waxy,  edematous, 
cyanotic  or  jaundiced,  special  odors  as  of  typhoid,  small  pox,  etc. 

b.  Note  condition  of  nails— discolored,  blue,  dry,  or  brittle. 

c.  Note  condition  of  hair  and  scalp. 

5.  Cough: — 

a.  Frequency  and  duration. 

b.  Character.     Whether  loose,  dry,  hard,  hacking,  or  painful. 

c.  Worse  when  sitting  or  lying. 

6.  Expectoration:— 

a.  Amount. 

b.  Character.     Mucous,  muco-purulent,  tenacious    (pneumo- 
nia), frothy,  rusty,  odor,  blood,  pure  pus.    The  sputum  should 
be  saved  for  inspection  by  the  physician. 

c.  Notice  the  way  in  which  the  sputum  is  brought  up. 

d.  Hygiene.     Have  the  patient  expectorate  in  a  square  of  tis- 
sue paper  and  burn.     A  sputum  cup  may  be  used.     If  lined 
with  paper  remove  the  paper  and  burn.     Boil  the  cup  daily. 

7.  Chills.     Goose  flesh,  shivering,  rigor.     Stages— shiver- 
ing, pyrexia,  sweating. 

Record  time  of  occurrence,  length  and  T.  P.  R. 

Always  report  a  chill  to  physician  or  head  nurse  as  soon  as 
possible.  Unless  otherwise  ordered  take  the  T.  P.  R.  frequently 
following  a  chill. 

8.  Delirium.     Quiet,    active,    muttering,    picking  at   bed- 
clothes or  imaginary  objects,  violent.     Delirious  patients  must 
not  be  left  alone. 

9.  Consciousness: — 

a.  Stupor.     Partial  unconsciousness  from  which  a  patient  can 
be  aroused. 

b.  Coma.     When  the  patient  can  not  be  aroused. 

c.  Coma  vigil.     Unconsciousness  with  the  eyes  open. 
10.  Special  Organs:— 

Ear:  a.  Swelling  or  tenderness. 

b.  Discharge. 

c.  Ringing  in  the  ears. 


10  GENERAL  NURSING 

d.  Difficulty  in  hearing. 
Eyes.    a.  Inflammation. 

b.  Presence  of  discharge,  serous  or  purulent. 

c.  Swelling  of  the  lids. 

d.  Oversecretion  or  lack  of  tears. 

e.  Unequal  dilatation  of  the  pupils  may  mean  a  very  serious 
condition  of  the  eyes  or  brain. 

f.  Squinting  or  strabismus. 

g.  Photophobia. 

Nose.    a.  Presence  or  absence  of  any  discharge,  and  its  char- 
acter. 

b.  Dilatation  of  alae  nasi  in  breathing. 
Mouth,    a.  Condition  of  teeth  and  gums. 

b.  Tongue.     Trembling,  coated,  furred,  fissured,  dry  indenta- 
tions of  teeth,  and  color  (light,  gray,  brown,  red),   strawberry 
tongue  as  in  scarlet  fever. 

c.  Breath.     Fetid  or  foul,  sweetish,  gangrenous,  odor  of  drugs 
or  anesthetics. 

11.  Sleep:— 

Quiet,  restful,  broken,  restless  when  asleep. 

Does  patient  sleep  all  night  but  waken  tired? 

Is  patient  hard  to  waken? 

Twitching  of  muscles,  muttering,  or  any  sign  of  delirium. 

12.  Pain:— 

a.  Origin.     Inflammatory — increased  by  pressure. 

Nervous — relieved  by  pressure. 

b.  Character.     Throbbing,  steady,  darting,  dull,  heavy,  neu- 
ralgic, grinding,  colicy, 

c.  Time.     When  most  severe.     Items  influencing  character. 
Constant,  intermittent  or  paroxysmal. 

d.  Location.     Pain  in  head — frontal,  occipital,   one-sided  as 
in  migraine  accompanied  by  nausea  or  vomiting  or  by  flashes 
or  spots  before  the  eyes. 

Pain  in  chest — may  be  accompanied  by  rapid  or  labored 
respiration  and  may  be  affected  by  change  in  position,  or  pre- 
sent only  on  deep  breathing. 

Pain  in  abdomen — continuous  or  spasmodic.  In  abdominal 
inflammations  the  knees  are  drawn  up  to  relieve  the  tension. 
Note  whether  the  pain  in  abdomen  is  localized;  if  so,  notice 
amount  of  tenderness,  rigidity  or  distention. 


BEDSIDE  RECORDS  11 

13.  Nausea  and  Vomiting. 

a.  Nausea  continuous  without  vomiting. 

b.  Vomiting  without  nausea. 

c.  Vomiting  after  taking  medicine  or  nourishment. 

d.  Color  of  ejected  matter — green,  bloody,  brown. 

e.  Odor  of  vomitus. 

14-  Hematemesis.     Vomiting  of  blood  from  the  stomach. 

The  ejected  matter  has  the  appearance  of  particles  like  cof- 
fee grounds  if  it  has  been  in  stomach  for  some  time;  if  fresh, 
dark  red  clots  with  an  acid  reaction,  and  may  be  mixed  with 
food  particles. 

15.  Hemoptysis.     Spitting  of  blood  from  the  lungs. 

It  is  raised  by  coughing  and  is  bright  red  in  color,  frothy, 
and  of  an  alkaline  reaction. 

16.  Food. 

a.  Amount. 

b.  Is  it  relished? 

c.  Cravings 

d.  Difficulty  in  swallowing. 

e.  Does  patient  masticate  thoroly? 

17.  Appetite. 

a.  Anorexia.    Absence  or  loss  of  appetite. 

b.  Bulimia.    Excessive,  morbid  hunger.     Notice  whether  ap- 
petite is  good  or  capricious. 

c.  Thirst.     Excessive  or  otherwise. 

18.  Facial   Expression.     Anxious,     pinched,     dull,    listless, 
tranquil.     Hot  flushes  of  face,  paleness,  cyanosis. 

The  visits  of  the  physician  should  always  be  recorded.  One 
great  point  of  distinction  between  the  trained  and  untrained 
nurse  is  the  ability  of  the  former  to  observe  accurately  and  to 
describe  intelligently  what  comes  under  her  notice. 


THE  SICK  -  ROOM 

Beds  and  Bed  Making 

Parts  and  materials.  Bed-steads  are  made  of  iron,  brass 
or  wood.  The  iron  bed-stead  is  the  best  because  it  is  easily 
cleaned,  simple,  durable,  and  of  medium  weight. 

The  spring's  should  be  made  of  woven  wire,  and  supported 
underneath  by  coiled  springs. 

Mattresses  are  made  of  wool,  hair,  felt,  straw,  or  moss.  In 
some  cases  air  or  water  mattresses  have  certain  advantages. 

MAKING   THE  BED.      SURGICAL 

1.  The  mattress  should  be  turned  daily  or  as  often  as  pos- 
sible. 

2.  Place  a  cotton  pad  the  same  dimensions  of  mattress  as 
to  length  and  width. 

3.  Rubber  draw  sheet.     The  upper  edge  at  lower  edge  of 
where  the  pillow  would  come.     The  lower  edge  should  reach 
well  below  the  hips. 

4.  The   cotton  sheet  should  be  3/4  yard  longer  than  bed 
and  wide  enough  to  tuck  in  well  on  both  sides.    Place  wide  hem 
at  the  top,   and  tuck  in  well  at  the  head  of  the  bed.     Draw 
tightly  and  tuck  firmly  at  the  foot.     Tuck  in  the  sides,  making 
square  corners.     Be  sure  that  the  sheet  is  put  on  straight,  for, 
if  not,  it  will  form  wrinkles. 

5.  Cotton  draw  sheet.     Fold  an  ordinary  sheet  lengthwise 
to  make  it  the  proper  width.     Place  the  folded  edge  at  the 
lower  edge  of  the  pillow.     Tuck  in  at  the  sides  snugly  and  firmly. 

6.  Upper  cotton  sheet.     About  9  inches  of  the  upper  edge 
should  be  allowed  to  turn  over  the  blanket.     Tuck  in  at  the 
foot,  making  square  corners  at  the  sides. 

7.  Blanket  and  spread.     The  folded  edge  of  the  blanket 
should  be  placed  at  the  foot. 

Items  to  be  heeded. 

1.  Avoid  linen  sheets.  They  absorb  moisture  from  body 
rapidly,  and  have  a  tendency  to  chill  the  patient.  They  are 
good  conductors  of  heat. 


BEDS  AND  BED  MAKING  13 

2.  Air  the  bedding  daily. 

3.  Exercise  economy  in  the  use  of  linen. 

4.  With  a  bed  patient,  generally  a  change  of  one  sheet  daily 
is  all  that  is  needed.     Take  the  under  sheet  for  the  draw  sheet 
and  the  top  sheet  for  the  under  sheet.     In  this  way  the  fresh 
sheet  will  be  at  the  top. 

5.  Fresh  blood  stains  can  be  removed  from  the  blankets 
or  ticking  by  spreading  over  the  spot  a  paste  of  fine  starch  or 
wheat  flour  and  allowing  it  to  dry.     Upon  rubbing  it  off,  if  the 
stain  is  not  entirely  removed,  a  second  application  will  generally 
be  effectual. 

6.  Remember  that  day  or  night  an  occasional  smoothing 
and  tucking  in  tightly  of  the  undersheet  and  draw  sheet  and  a 
straightening  of  the  top  sheet  as  well  as  the  shaking  and  turn- 
ing of  pillows,  adds  much  to  the  comfort  of  the  patient. 

7.  Keep  the  bed  free  from  crumbs  and  wrinkles. 

8.  When  there  is  danger  of  the  bed  being  soiled  frequently, 
place  the  rubber  sheet  directly  under  the  draw  sheet. 

9.  A  neatly  kept  and  fresh  looking  bed  always  speaks  well 
for  the  nurse. 

THE   OBSTETRICAL  BED 

1.  Make  the  bed  as  for  a  surgical  patient. 

2.  Pad  with  newspapers. 

3.  Pin  over  this  a  clean  sheet.     Have  sterile  if  possible. 

4.  Kelly  pad.     This  convenience  often  has  to  be  dispensed 
with  in  private  practice.     It  can  be  substituted  by  hip  pads 
which  should  be  changed  as  often  as  necessary. 

5.  After  delivery  the  newspapers  and  pads  are  removed 
and  the  patient  is  on  a  fresh,  clean  bed. 

THE   FRACTURE   BED 

Make  up  a  bed  as  for  a  surgical  patient. 

Place  under  the  mattress  a  fracture  board  made  of  slats 
one  inch  thick  and  three  inches  wide.  This  will  be  lighter  and 
afford  better  ventilation  than  a  board  that  is  not  perforated. 

A  fracture  bed  must  be  firm  and  unyielding. 


14  GENERAL  NURSING 

CHANGING  BED   LINEN 

This  should  be  done  with  as  little  fatigue  and  discomfort  to 
the  patient  as  possible. 

1.  Losen  the  bedding  on  all  sides. 

2.  Leave  only  the  upper  sheet  or  a  single  blanket  over  the 
patient,  who  should  be  placed  as  near  one  edge  of  the  bed  as 
possible. 

3.  The  lower  sheet  and  draw  sheet  are  then  folded  separ- 
ately on  one  side  along  their  whole  length  as  flatly  as  possible 
until  they  are  close  to  the  patient. 

4.  Take  the  fresh  sheet,   fold  it  lengthwise,  place  on  bed 
with  the  folded  edge  as  near  the  middle  as  possible,   and  tuck 
in  the  under  half  at  the  ends  and  side.     The  remaining  half  is 
folded  lengthwise  alternately  backward  and  forward  and  placed 
close  to  patient  under  the  soiled  sheet. 

5.  Fold  the  draw  sheet  and  place  over  this  the  under  sheet. 

6.  The  nurse  then  goes  to  the  opposite  side  of  the  bed  and 
turns  the  patient  on  the  side  with  face  toward  her.     She  can 
hold  the  patient  in  this  position  with  one  hand  and  tuck  the 
sheets  to  be  removed  as  close  to  the  back  of  the  patient   as 
possible.     The  fresh  sheets  are  brought  over  to  cover  the  place 
occupied  by  the  soiled  ones. 

7.  The  nurse  then  gently  turns  the  patient  on  the  back  and 
toward  the  opposite  side  of  the  bed. 

8.  The  soiled  sheets  are  quickly  removed  and  the  fresh 
ones  drawn  into  place.     Tuck  in  snugly  on  all  sides. 

9.  Place  the  fresh  top  sheet  over  the  soiled  one,  and  pull 
the  latter  out  from  underneath. 

If  a  patient  is  quite  helpless  it  will  take  a  second  person  to 
assist.  If  the  patient  is  not  able  to  be  turned,  the  bed  linen 
should  be  changed  from  the  head  of  the  bed  toward  the  foot. 
The  fresh  sheet  is  folded  crosswise  alternately  backward  and 
forward.  The  shoulders  and  back  must  be  raised  and  sheet 
worked  down.  Then  raise  the  hips  and  pull  the  sheet  still  far- 
ther down.  Continue  until  it  is  tucked  under  at  the  foot  of 
the  bed. 

CHANGING  GOWN 
All  hospital  patients  should  have  gowns  that  are  open  in 


BEDS  AND  BED  MAKING  U 

the  back,  as  they  are  much  more  easily  changed.  However,  a 
nurse  often  has  to  change  a  gown  opening  in  the  front,  which 
is  the  kind  ordinarily  worn. 

1.  Removing  the  soiled  gown. 

a.  Lift  hips  and  slip  the  soiled  gown  above  the  hips. 

b.  Lift  the  shoulders  and  slip  the  gown  above  the  shoulders. 

c.  Remove  one  sleeve  and  slip  the  gown  over  the  head. 

d.  Then  the  last  sleeve  is  easily  removed. 

2.  To  put  on  fresh  gown. 

a.  Gather  the  gown  up  in  such  a  way  that  it  forms  a  circle. 

b.  Place  on  the  chest,  so  that  the  folds  in  the  center  of  the 
back  will  be  just  beneath  the  chin. 

c.  Sleeves  should  then  be  carefully  put  on.     Lift  the  head 
gently.     Slip  the  garment  over  it  and  draw  it  down  over  the 
shoulders. 

LIFTING  THE  PATIENT 

1.  To  move  a  patient  in  bed,  the  nurse's  right  hand  should 
be  placed  well  under  the  upper  part  of  the  patient's  back,   and 
around  the  opposite  shoulder.     The  "left  hand  is  put  over  the 
patient  and  slipped  under  the  back.  The  patient  places  her  arm 
around  the  nurse's  neck  if  she  is  able  to  assist.     Otherwise  the 
nurse's  left  arm  should  be  placed  under  the  patient's  back  a 
little  below  the  shoulders  and  from  the  same  side.     Then  lift 
gently.     The  lower  half  of  the  body  is  now  lifted  in  the  same 
way. 

2.  It  is  better  that  three  nurses  should  do  the  lifting  if  the 
patient  is  very  heavy  or  feeble.    These  three  nurses  must  stand 
on  the  same  side  of  the  bed  in  this  case  at  the  patient's  left. 

Nurse  No.  1.  Place  the  right  arm  under  the  back  of  the 
neck  and  the  head  of  the  patient  in  such  a  way  as  to  support 
the  head  (lifting  pillow  under  the  head),  and  place  the  left 
hand  under  the  lower  part  of  the  shoulders. 

Nurse  No.  2.  Place  the  right  arm  under  the  back  at  the 
waist  line  and  the  left  arm  under  the  hips. 

Nurse  No.  3.  Place  the  right  hand  under  the  thighs  just 
above  the  knees,  and  with  the  left  hand  support  the  feet. 

All  should  lift  at  the  same  time.  Have  the  patient's  arms 
folded  over  the  chest  and  see  that  she  is  covered  with  a  sheet. 
Many  nurses  complain  of  having  strained  their  backs  lifting; 


16  GENERAL  NURSING 

but  this  is,  as  a  rule,  unnecessary  if  the  underlying  principles 
of  "lifting"  are  observed.  Remember  the  following:  Always 
bend  from  the  hips,  keeping  the  spine  straight.  Separate  the 
feet  and  bend  the  knees.  Let  the  weight  fall  on  the  arms  and 
legs.  In  this  way  heavy  people  may  be  lifted  with  comparative 
ease. 

To  lift  patient  toward  the  head  of  bed.  The  right  hand  is 
placed  well  under  the  back,  the  heavy  part  of  the  shoulder 
being  supported  with  the  upper  part  of  the  arm  and  shoulder. 
The  left  hand  is  placed  below  the  hip.  Lift  gently  and  firmly. 

PREPARATION   FOR   GIVING   DOUCHE   AND   ENEMA 

Have  in  readiness  at  least  six  pillows,  a  newspaper  pad 
with  a  towel  over  it,  a  "perfection"  bed  pan  which  has  been 
warmed,  also  plenty  of  newspapers.  If  the  patient  is  entirely 
helpless  three  nurses  should  gently  lift  the  patient  as  previously 
described  and  the  regular  nurse  from  the  opposite  side  of  bed, 
slip  three  pillows  under  the  head,  two  under  the  shoulders  and 
one  under  the  lower  back. 

The  newspaper  pad  is  then  placed  where  the  hips  would 
come,  and  the  bed  pan  next  with  a  small  pad  upon  it.  The  pa- 
tient is  then  gently  lowered  onto  the  pan  and  pillows.  The 
knees  and  feet  are  supported  and  a  newspaper  "dash  board" 
placed  in  the  pan.  The  patient  should  be  in  as  comfortable  a 
position  as  possible  and  the  nurse  be  sure  that  the  pan  is  on  a 
level.  When  thru,  remove  the  pan,  and  cover  it  with  a  news- 
paper. Cover  the  patient  and  remove  the  pan  from  the  room 
as  quickly  as  possible.  Finally  wash  the  patient  and  remove 
newspaper  and  surplus  pillows. 

WHEEL  CHAIRS 

Wheel  chairs  can  be  firmly  padded  with  pillows  and  made 
just  as  comfortable  as  a  bed. 

Place  one  large  pillow  lengthwise  at  the  back,  one  cross- 
wise in  the  seat  of  the  chair,  one  lengthwise  under  the  legs, 
and  one  over  the  angle  of  the  seat.  Put  a  blanket  over  these 
and  lift  the  patient  carefully  from  the  bed  to  the  chair.  Place 
extra  pads  and  cushions  where  they  seem  to  be  needed  to  make 
the  patient  comfortable.  Special  blankets  should  be  provided 
for  the  outer  covering  instead  of  bed  blankets.  Tuck  the  pa- 


BEDS  AND  BED  MAKING  17 

tient  in  snugly  if  going  out  of  doors  or  if  the  chair  is  to  be 
placed  where  the  patient  will  be  exposed  to  cold  in  any  way. 

THE  SICK  ROOM  ITSELF 

Location.  If  possible  choose  a  large  room  on  the  sunny  side 
of  the  house  and  as  near  conveniences  as  possible.  It  should  be 
airy  and  quiet.  There  should  be  a  good  dressing  room  where 
all  clothing,  linen,  dressings,  medicines  and  appliances  may  be 
kept. 

Furnishings.    The  following  may  be  considered  ideal:— 

1.  The  walls  and  ceiling  should  be  hard  finished  and  of  a 
soft  tint  that  will  be  restful  to  the  eyes. 

2.  Bed — An  iron  bed  if  possible, — a  regular  surgical  bed  is 
better. 

3.  Easy  chair  and  a  straight  chair. 

4.  Screen. 

5.  Wheel  chair  at  hand  if  possible. 

6.  Washstand. 

7.  Dresser. 

8.  Bedside  table. 

9.  Center  table. 

10.  Woolen  and  heavy  draperies  should  be  avoided.     The 
curtains  should  be  of  a  light  washable  material 

Sick  room  appliances: — 

1.  Drinking  tubes.  7.  Bed  rests. 

2.  Square  cotton  pads.  8.  Bed  cradle. 

3.  Long  cotton  pads.  9.  Kidney  pan. 

4.  Rubber  air  cushions.  10.  Urinal. 

5.  Heel  cushions.  11.  "Perfection"  bed  pan. 

6.  Bed  cushion. 

Hygiene  of  the  sick  room:— 

The  temperature  must  be  kept  as  even  as  possible.  From 
65°  to  70°  F.  The  air  must  be  kept  pure  and  cool.  The  nurse 
should  be  diligent  in  securing  good  ventilation.  In  the  winter 
time  in  almost  every  case  the  window  can  be  dropped  one  and 
one-half  inches  from  the  top.  Hot  air  rises  and  displaces  the 
cold  air,  which  becomes  warm  as  it  descends. 

A  board  from  four  to  six  inches  wide  may  be  placed  under 
the  lower  sash  and  fresh  air  will  enter  between  the  sashes, 
2 


18  GENERAL  NURSING 

thus  preventing  a  draught.  Opening  a  window  widely  at  top 
and  bottom  and  covering  patient,  will  air  the  room  thoroly.  If 
the  patient  is  afraid  of  draughts  an  umbrella  may  be  held  over 
him  or  a  screen  placed  before  the  bed.  This  may  be  done  three 
or  four  times  a  day. 

A  fire-place  is  an  excellent  ventilator.  A  small  fire  can 
easily  be  made  and  it  not  only  assists  good  ventilation  but  gives 
a  cheerful  aspect  to  the  room. 

Three  thousand  cubic  feet  of  air  should  be  supplied  each 
person  in  an  hour. 

Place  the  bed  so  that  the  light  will  not  shine  directly  in  the 
patient's  eyes.  At  night  the  lights  should  be  shaded  and  in  the 
day  time  the  patient's  eyes  should  be  protected  from  the  full 
glare  of  light. 

All  excreta  and  soiled  linen  should  be  removed  from  the 
room  as  soon  as  possible,  as  they  are  sources  of  contamination. 
In  removing  vomited  matter,  evacuations  from  the  bowels  or 
bladder,  cover  the  vessel  or  pan  with  a  towel  or  rubber  cloth. 
The  room  should  be  kept  free  from  dust.  Absolute  cleanliness 
should  be  the  slogan  of  the  sick  room. 

How  to  clean  surgical  room: — 

1.  Dust  all  furniture  daily  with  a  cloth  slightly  oiled. 

2.  Keep  the  crockery  clean  and  shining. 

3.  Wash  the  floor  daily. 

4.  When  dust  accumulates  on  the  floor  during  the  day  wipe 
it  up  with  a  damp  cloth  or  with  a  broom  covered  with  a  damp 
cloth. 

5.  Keep  fresh  covers  on  the  dresser  and  stands. 

6.  Provide  yourself  with  a  cloth  for  dusting  furniture,  and 
one  for  washing  crockery.     A  separate  floor  cloth  should  be 
provided. 

How  to  clean  room  of  non-surgical  patient:— 

1.  If  possible  remove  rugs  and  clean  them  outside. 

2.  If  rugs  are  too  large  and  heavy  to  be  removed,   use  a 
carpet  sweeper  and  then  wipe  them  with  a  damp  cloth,  or  use 
a  vacuum  cleaner. 

3.  If  a  carpet  sweeper  is  annoying  to  patient,  the  rug  will 
have  to  be  cleaned  with  a  damp  cloth,  at  least  once  a  day,  and 
sometimes  twice. 


BEDS  AND  BED  MAKING  19 

4.  In  other  points  the  cleaning  is  the  same  as  in  a  surgical 
room. 

5.  If  patient  is  able  to  be  taken  out  in  a  wheel  chair,  the 
room  can  be  cleaned  much  more  thoroly  during  her  absence. 

6.  Wipe  off  all  articles  and  place  on  the  bed;  cover  with  a 
sheet.      Then  clean  the   entire  room  thoroly  and  replace  the 
articles. 

7.  Do  not  neglect  the  polishing  of  faucets  if  there  is  a  sta- 
tionary bowl  in  the  room. 

General  items: — 

1.  Put  all  waste  and  soiled  linen  in  places  provided  for  the 
purpose. 

2.  Always  line  the  waste  basket  with  a  newspaper. 

3.  Keep  fresh  flowers  tastefully  arranged  in  the  room  of 
your  patient. 

4.  Be  careful  to  keep  contents  of  bureau  and  washstand 
drawers  in  proper  order.     The  closet  should  also  be  kept  in 
perfect  order. 

5.  Do  not  set  glasses  of  fruit  juice  or  other  liquids  that 
may  cause  stains  on  dresser  or  stand  covers,   but  see  that  a 
plate  is  placed  underneath  them.     Always   rinse   a  drinking 
tube  after  the  patient  takes  anything  but  water.     Keep  the 
pitcher  of  drinking  water  covered. 

6.  Provide  yourself  with  the  needed  cleaning  cloths,  and 
wash  them  when  necessary. 

7.  Have  a  place  for  everything  and  keep  everything  in  its 
place. 

8.  Keep  faucets  in  the  room  polished  and  scrub  the  bedpan 
and  urinal  daily.     Urinal  brushes  may  be  used  to  clean  urinals. 

9.  Do  not   allow   treatment  bowls   to  become   dark   and 
stained.     If  they  are  properly  cleaned  daily  they  can  be  kept 
perfectly  white. 

10.  Do  not  set  bottles  of  alcohol  or  bowls  or  pails  containing 
hot  substances  on  the  furniture  unless  very  well  protected. 

Proper  attention  to  details  characterizes  the  successful 
nurse.  Let  each  keep  a  high  ideal  in  view  and  strive  to  make 
progress  each  day. 

PERSONAL  CARE  OF  PATIENT 
1.  Morning  and  evening  toilet.     Wash   the   face,    hands, 


20  GENERAL  NURSING 

neck  and  ears,   clean  the  nails,   comb  the  hair,  brush  the  teeth 
and  wash  the  mouth. 

2.  Keep  the  bed  fresh  and  free  from  wrinkles  and  crumbs. 

3.  See  that  the  patient  is  as  comfortable  as  possible. 

4.  Keep  the  toe  nails  clean  and  trimmed. 

5.  Give  thoro  and  careful  treatment. 

6.  See  that  the  food  is  served  properly. 

7.  Anticipate  the  needs  of  your  patient. 

8.  Be  neat  and  clean  in  your  personal  appearance,  as  this 
is  a  duty  you  owe  not  only  to  your  patient  but  also  to  yourself. 

9.  Properly  ventilate  the  room. 

10.  Do  not  talk  too  much.     Avoid  gossip. 

11.  Endeavor  to  minister  in  the  spirit  of  the  Master. 


CLINICAL  PROCEDURES 

Lavage 

1.  Articles  necessary:— 

a.  Sheet. 

b.  One-half  dozen  napkins. 

c.  Pail  of  drinking  water  (105°). 

d.  Quart  pitcher. 

e.  Lavage  tube. 

f.  Washbowl. 

g.  Slop  jar. 

2.  Giving  lavage: — 

a.  Have  the  patient  remove  collar  and  loosen  every  constrict- 
ing garment.     Also  remove  false  teeth. 

b.  Have  the  patient  sit  in  a  chair. 

c.  Fasten  a  folded  sheet  around  the  neck  in  such  a  way  as  to 
protect  the  clothing  perfectly. 

d.  Fold  the  napkin  under  the  chin. 

e.  Place  the  slop  jar  in  front  of  patient  with  bowl  on  top  of  it. 

f .  The  pail  of  water,  pitcher  and  napkins  should  be  within 
easy  reach. 

g.  The  tube  should  be  wet  in  the  drinking  water  before  being 
passed. 

h.  Placing  left  arm  around  patient's  neck  in  such  a  way  as 
to  support  the  tube,  the  patient  is  requested  to  open  mouth  and 
swallow  as  the  tube  touches  the  back  part  of  the  throat.  In- 
struct patient  to  breath  thru  the  mouth. 

i.  In  the  average  case  pass  tube  about  16  inches. 

j.  Coughing  and  cyanosis  indicate  that  the  tube  has  been 
passed  into  the  trachea.  Withdraw  it  immediately. 

k.  After  the  tube  is  passed,  pour  in  about  a  pint  of  water, 
and  when  tube  is  about  empty,  quickly  lower  it  over  bowl  and 
allow  the  water  to  siphon  out  of  the  stomach.  Empty  the  water 
into  the  jar  underneath. 

1.  If  the  water  does  not  come  quickly  withdraw  the  tube 
slightly  and  tell  the  patient  to  contract  the  abdominal  muscles. 

m.  Repeat  washing  until  the  water  returning  is  perfectly 
clear. 


22  GENERAL  NURSING 

n.  The  napkin  should  be  changed  as  often  as  needed  to  keep 
mouth  free  from  mucus  and  saliva. 

o.  Remove  the  tube  quickly.  Give  the  patient  a  napkin  to 
dry  the  mouth. 

p.  Encourage  the  patient  and  endeavor  to  allay  all  fears. 

3.  Cleansing  of  tube:— 

a.  Rinse  in  clear  water. 

b.  Wash  in  strong  soap  suds. 

c.  Rinse  again. 

d.  Let  stand  one-half  hour  in  a  solution  of  formaldehyde, 
using  25  c.  c.  of  the  formalin  to  a  quart  of  water. 

e.  Rinse  again  and  dry. 

f.  Place  in  a  clean  napkin. 

g.  The  lavage  outfit  (pail,  pitcher,  and  tube)  should  always 
be  returned  to  the  cupboard  in  perfect  order  and  ready  for  use. 

The  Test  Breakfast 

1.  The  breakfast  itself:— 

a.  No  food  or  water  should  be  taken  after  rising  in  the  morn- 
ing before  the  time  for  eating  the  meal. 

b.  At  the  time  appointed  for  the  meal,  the  patient  should  eat 
1  1/2  oz.  granose  (dry),  taking  about  25  minutes  to  eat  it,  being 
careful  to  masticate  thoroly  every  particle. 

c.  The  patient  should  then  take  200  c.  c.  of  water. 

d.  The  patient  should  then  lie  on  the  left  side  until  one  hour 
from  beginning  to  eat  the  granose. 

2.  To  take  up  the  breakfast  have  the  following  articles  in 
readiness:    2  glasses,  lavage  tube,  sheet,  napkins,  large  bowl. 

a.  At  the  appointed  time  have  the  patient  sit  in  a  chair. 
Place  a  sheet  around  him,  with  a  bowl  in  front  on  the  floor. 

b.  The  nurse  should  scrub  her  hands  thoroly. 

c.  Pass  the  tube  as  in  giving  a  lavage. 

d.  Place  a  glass  in  the  bowl. 

e.  Stand  in  front  of  the  patient.     Pinch  tube  above  the  bulb 
with  thumb  and  first  finger  and  immediately  compress  bulb 
with  remaining  fingers. 

f.  Immediately  the  air  is  pressed  out  of  the  bulb,  pinch  the 
tube  below  the  bulb  and  release  the  bulb. 

g.  Have  the  patient  lean  forward  and  contract  the  abdominal 
muscles,  pressing  the  hands  over  the  stomach  at  the  same  time. 


THE  TEST  BREAKFAST  23 

This  generally  fills  the  bulb;  if  not,  draw  tube  out  a  few  inches 
and  pass  back  again.  When  the  bulb  is  full,  grasp  the  tube 
again  above  the  bulb  and  press  the  contents  into  the  glass. 

h.  Repeat  the  above  procedure  until  the  stomach  is  emptied 
or  until  a  sufficient  amount  has  been  gained  for  a  test. 

i.  Next  pour  into  the  funnel  100  c.  c.  of  distilled  water.  Al- 
low sufficient  time  for  the  water  to  pass  entirely  out  of  the 
stomach  tube. 

j.  Instruct  the  patient  to  move  the  abdominal  wall  in  and 
out  rapidly  so  as  to  mix  the  water  with  the  remaining  contents 
of  the  stomach. 

k.  Remove  as  much  as  possible  of  this  mixed  fluid  putting  it 
into  the  second  glass. 

1.  Some  prefer  the  use  of  a  large  suction  bulb  which  is  so 
constructed  as  to  be  quickly  attached  to  and  removed  from  the 
tube.  The  contents  of  the  stomach  is  drawn  out  into  this  bulb 
which  is  removed  and  emptied  into  the  glass. 

m.  Remove  the  tube  quickly  and  press  out  the  remaining 
contents  into  the  glass. 

n.  Clean  all  articles  as  after  a  lavage.  Reset  the  tray  and 
return  to  the  cupboard. 

o.  Label  the  first  taken  up  "Test  Meal,"  the  second  "Lavage 
Specimen." 

Nasal  Douche 

1.  Small  irrigating  can,  placed  one  foot  above  the  patient. 

2.  Temperature  100°. 

3.  Saline  solution  (1  teaspoonful  to  1  pint  of  water).    Plain 
water  is  more  painful  because  more  quickly  absorbed,  causing 
fullness  and  pressure. 

4.  A  nasal  tube  should  be  attached  to  the  rubber  tubing. 

5.  Care  as  to  position.     The   patient   should  sit  with  the 
head  bent  forward  over  a  receptacle.     The  mouth  should  be 
open  so  that  air  can  pass  thru  it. 

6.  The  tube  should  be  inserted  into  one  nostril.    The  water 
will  flow  out  thru  the  other  nostril. 

7.  The   patient   should   never   swallow   while   taking  the 
douche,   as  this  opens  the  Eustachian  tube,    and  may  injure 
the  ear. 

8.  The  douche  should  be  copious,  one  quart  or  more. 


24  GENERAL  NURSING 

Aural  Douche 

1.  Same  can  as  for  the  nasal  douche,  or  a  smaller  one. 

2.  Attach  the  aural  tube  to  the  rubber  tubing. 

3.  Solution  as  prescribed  should  be  used.     For  earache  or 
pain,  the  temperature  should  be  105°  to  108°,   as  can  be  borne. 

4.  For  softening  and  removing  wax,  the  douche  should  be 
given  at  low  pressure,  the  can  on  a  level  with  the  auditory  canal. 

5.  A  tray  should  be  held  under  the  ear,  and  the  water  be 
allowed  to  run  in  a  continuous  stream. 

6.  Patient  may  be  in  a  sitting  or  reclining  position. 

7.  Never  introduce  anything  cold  into  the  ear. 

8.  Do  not  be  alarmed  if  the  patient  becomes  dizzy — simply 
stop  the  water  for  a  few  minutes  and  remove  the  water  in  the 
ear  by  a  pledget  of  absorbent  cotton.     When  thru,  dry  the  ear 
by  applying  cotton. 

9.  Never  use  medicines  in  the  ear  without  a  prescription, 
and  then  be  sure  they  are  thoroly  dissolved. 

10.  If  a  patient  is  going  out  after  treatment,  put  a  little 
cotton  into  the  outer  ear  and  instruct  the  patient  to  remove  it 
on  coming  in. 

Hypodermatic  Injections 

A  hypodermatic  injection  is  the  introduction  of  a  medicine 
under  the  skin  by  a  specially  constructed  syringe,  designed 
to  produce  a  more  rapid  and  certain  effect  than  can  be  gained 
if  the  medicine  is  given  by  mouth  or  per  rectum.  The  most 
convenient  places  for  injection  are  the  outside  of  the  arms,  the 
forearms,  the  thighs,  the  chest,  and  the  abdomen.  Avoid  bones, 
large  blood  vessels,  and  nerves.  Insert  the  needle  into  a  fleshy 
part. 

1.  Cleansing  of  needle  and  syringe:— 

a.  Boil  or  otherwise  thoroly  disinfect  the  whole  instrument  at 
frequent  intervals. 

b.  At  other  times  the  barrel  may  be  cleansed  by  washing  in 
alcohol  and  rinsing  with  boiled  water. 

c.  Boil  the  needle  or  disinfect  in  alcohol  before  using. 


HYPODERMATIC  INJECTIONS  25 

2.  The  hypodermic  tray  contains  the  following  articles:— 

a.  alcohol  lamp.  e.  small  bottle  of  alcohol  95%. 

b.  a  spoon.  f.       "         "      "  boiled  water. 

c.  matches.  g.  2  small  glasses. 

d.  a  small  jar  filled  with  h.  the  medicine  to  be  used. 

cotton  balls. 

3.  Technique  of  administration: — 

a.  Pour  alcohol  into  one  glass,  and  boiled  water  into  the  other. 

b.  Cleanse  the  barrel  of  the  syringe  as  directed. 

c.  Boil  the  needle  in  a  teaspoon  over  the  alcohol  flame. 

d.  Pour  off  water  carefully  and  place  the  needle  on  the  barrel, 
being  careful  not  to  touch  the  point. 

e.  Put  the  tablets  ordered  into  the  spoon  and  pour  on  the 
proper  amount  of  boiled  water.     Dissolve  over  flame  and  draw 
the  solution  into  the  barrel  of  the  syringe. 

f.  See  that  the  air  is  expelled  from  the  barrel. 

g.  Disinfect  the  skin  with  alcohol,  grasp  the  fleshy  part  be- 
tween the  thumb  and  finger,  and  insert  the  needle  in  a  slanting 
direction. 

h.  Withdraw  the  needle  slightly,  and  inject  the  fluid  slowly, 
i.  Quickly  remove  the  needle  and  place  a  cotton  pledget  over 
the  part,  making  a  slight  pressure. 

j.  Cleanse  the  needle  and  syringe  with  alcohol. 

k.  Put  a  small  wire  thru  the  needle  to  keep  it  from  rusting. 

1.  Always  leave  the  tray  in  perfect  order. 

4.  Precautions.    If  the  needle  and  solution  are  not  clean, 
abscesses  are  liable  to  develop. 

Never  give  a  hypodermic  without  an  order  from  the  phy- 
sician, and  do  not  repeat  without  definite  order  to  do  so. 

Catheterization  and  Bladder  Irrigation 

The  normal  amount  of  urine  secreted  daily  averages  forty 
ounces  or  1200  c.  c. 

An  absence  of  the  urinary  excretion,  owing  to  a  failure  of 
the  kidneys  to  act,  is  known  as  suppression. 

Retention  is  the  failure  to  expel  that  which  is  contained  in 
the  bladder. 

Incontinence  is  the  involuntary  passing  of  urine. 

Cystitis  is  an  inflammation  of  the  lining  of  the  bladder. 


26  GENERAL  NURSING 

Whenever,  from  any  cause,  a  patient  is  unable  to  pass  urine 
voluntarily,  the  catheter  should  be  used  every  six  or  eight  hours. 

1.  Articles  needed  for  catheterization: — 

a.  Two  medium  sized  bowls.    The  first  contains  two  catheters 
of  glass,  metal,  rubber,  or  lysle  thread;  the  second  a  disinfect- 
ant solution,  HgCk— 1 — 3000,  boracic  acid— sat.  sol,  creasopeor 
lysol— 1/2%,  green  soap— 2  1/2%. 

b.  A  package  of  sterile  sponges,  or  cotton  pledgets. 

c.  Sterile  lubricant — vaseline  or  any  good  oil,  if  sterile. 

2.  General  procedure:— 

a.  Boil  the  catheter  ten  minutes.     In  the  meantime  the  pa- 
tient should  be  gotten  ready. 

b.  Place  a  folded  towel  under  the  hips.    Cover  the  limbs  with 
a  sheet,  if  the  room  is  cold,  use  a  light  blanket  and  also  a  sheet. 
Do  not  unnecessarily  expose  the  patient.     Scrub  your  hands 
thoroly. 

c.  After  the  catheter  is  boiled,  place  a  tray  between  the  limbs 
of  the  patient,  also  a  urinal  or  receptacle  for  receiving  the  urine. 

d.  Open  a  package  of  sponges,  being  careful  not  to  touch 
them. 

•e.  Open  the  tube  of  lubricant,  discard  the  first  portion,  and 
then  squeeze  out  a  small  portion  onto  a  sterile  sponge. 

f .  Dip  the  right  hand  into  a  disinfectant.    Wet  a  clean  sponge 
in  the  disinfectant  solution  and  wash  thoroly  the  part  all  about 
and  over  the  meatus  urinarius. 

g.  Dip  the  hand  again  in  the  desinfectant  with  a  fresh  sponge, 
wash  the  meatus  urinarius  with  sterile  water. 

h.  Grasp  the  catheter  below  the  part  that  will  enter  the  blad- 
der, lubricate  it  with  the  oil  previously  placed  on  the  sterile 
sponge,  and  insert  into  the  urethra.  Pass  gently  along  until 
the  urine  flows.  If,  after  the  catheter  has  been  inserted  the 
necessary  distance,  the  urine  does  not  pass,  withdraw  slightly, 
turn  and  then  insert  farther  than  before. 

i.  If  the  bladder  is  excessively  distended  do  not  empty  at  one 
time,  as  undesirable  symptoms  are  apt  to  follow  Draw  only  a 
portion  and  in  a  short  time  repeat  the  process. 

j.  When  the  urine  has  ceased  to  flow,  compress  the  catheter 
or  put  the  finger  over  the  end,  so  that  no  urine  will  escape  and 
soil  the  bed,  while  the  catheter  is  being  withdrawn. 


CATHETERIZATION  27 

k.  Sponge  the  meatus  urinarius  with  boiled  water.     Measure 
the  urine  and  record  the  quantity  and  character  of  the  same. 

3.  Special  procedure  in  the  male.     The  male  urethra  is  from 
7  to  8  inches  in  length  and  is  divided  into  three  portions;  the 
anterior  or  penile  portion  about  six  inches  long,  the  membranous 
portion  about  a  half  inch  long,  and  the  prostatic  part  one  inch 
in  length.    The  posterior  end  of  the  penile  portion  is  wider  than 
the  anterior  part,   and  the  prostatic  portion  is  the  widest  and 
most  variable  in  shape,   size,   and  length.     It  is  in  these  two 
parts  that  a  rubber  catheter  is  most  likely  to  double  upon  itself 
and  in  the  prostatic  portion  the  obstruction  of  an  enlarged  pro- 
state may  make  its  passage  difficult. 

For  use  in  the  male  urethra  catheters  are  made  of  soft  rub- 
ber, semiflexible  (black)  rubber,  metal  or  lysle  thread.  If  dif- 
ficulty is  experienced  in  passing  an  ordinary  rubber  catheter, 
an  olivary  tipped  black  rubber  or  lysle  thread  catheter  should 
be  tried.  In  passing  a  metal  catheter  it  must  be  specially  di- 
rected. This  requires  demonstration. 

Before  passing  the  catheter,  grasp  the  organ  with  a  napkin 
just  below  the  glans  and  wash  thoroly  the  entire  glans.  Fol- 
low by  washing  with  a  disinfectant.  A  sponge  of  absorbent 
cotton  dipped  in  the  disinfectant  should  be  left  over  the  glans 
while  other  preparation  is  being  made.  In  passing  the  catheter 
straighten  the  urethra  by  gentle  traction,  go  slowly  and  with- 
draw the  catheter  if  an  obstruction  is  met,  turning  it  around 
advance  it  again.  If  a  reasonable  amount  of  gentle  careful 
work  does  not  succeed,  summon  the  head  nurse  or  the  physician 
in  charge.  ,i 

4.  Special  procedure  in  the  female.     With  the  left  hand  sep- 
arate the  labia  and  hold  apart  during  washing  and  disinfect- 
ing the  parts  and  inserting  the  catheter. 

The  meatus  urinarius  is  variously  located  in  different  pa- 
tients. In  one  you  will  discover  it  high.  In  another  case  it 
may  be  much  lower,  even  in  the  opening  of  the  vagina.  By 
careful,  close  inspection  the  meatus  will  readily  be  found. 

The  urethra  varies  much  in  length.  In  a  thin  patient  it 
may  be  but  one  inch  or  more  from  the  meatus  to  the  bladder. 
In  a  large,  fleshy  patient  the  urethra  may  be  even  three  inches 
in  length.  Govern  the  passing  of  the  catheter  accordingly. 


28  GENERAL  NURSING 

When  you  remove  the  catheter  place  a  sponge  over  the  va- 
ginal opening  to  prevent  the  entrance  of  any  urine. 

5.  After-care  of  tray. 

a.  Run  plain  water  thru  the  catheter,   then  soapsuds,    and 
rinse  again  with  plain  water.     Let  it  stand  in  a  disinfectant 
solution  15  minutes.     Rinse  in  water  and  wipe  dry. 

b.  Wash  bowls  and  tray  in  soapsuds  and  disinfect  in  the  sol- 
ution used  for  the  catheter.     Wipe  dry. 

c.  Place  the  catheter  in  one  bowl  with  the  other  over  it.     Put 
the  lubricant  on  the  tray  and  also  a  package  of  fresh  sponges. 

6.  Irrigation.     In  case  bladder  irrigation  is  to  be  given,   in 
addition  to  the  above  preparation,   prepare  an  irrigating  can 
containing  a   sterile   solution    (saline,    permanganate,   boracic 
acid,  or  whatever  may  be  ordered) .    Attached  to  the  irrigating 
can  is  rubber  tubing,  at  the  end  of  which  is  inserted  a  sterile 
glass  irrigator  point. 

After  the  patient  is  catherized,  the  rubber  catheter  is  not 
removed  but  the  tip  of  the  glass  tube  is  inserted  into  the  cathe- 
ter. Be  sure  that  all  air  is  expelled  before  this  connection  is 
made.  Allow  about  200  c.  c.  of  solution  to  enter  the  bladder, 
unless  the  patient  complains  of  pain,  then  disconnect  the  irri- 
gator point  and  let  the  solution  flow  from  the  bladder.  Repeat 
same  until  the  bladder  is  clean.  Then  remove  the  catheter  ac- 
cording to  directions  for  catheterization. 

Many  prefer  a  glass  funnel  instead  of  the  irrigating  can  in 
giving  irrigations,  and  some  use  a  glass  syringe.  A  small-size 
glass  funnel  or  small  glass  syringe  is  very  much  handier  for  the 
instillation  of  medicaments  into  the  bladder  or  urethra. 

Carelessness  on  the  part  of  the  nurse  in  catherization  has 
often  resulted  in  cystitis.  One  must  be  thoroly  conscientious 
in  all  details  else  weeks  of  needless  suffering  may  result. 

Nasal  Feeding 

When  patients  refuse  food  by  the  mouth,  it  is  oftentimes 
necessary  to  resort  to  nasal  feeding.  A  nurse  should  never 
attempt  this  unless  she  has  at  least  seen  it  done,  or  has  assisted 
some  one  else.  Never  be  afraid  to  say,  "I  don't  know,"  for 
otherwise  you  may  bring  much  unnecessary  suffering  to  a  pa- 
tient. 


THE  NUTRIMENT  ENEMA  29 

If  a  patient  resists  at  all,  there  should  be  two  attendants 
to  hold  him  in  the  proper  position— either  sitting  or  lying. 

1.  Articles  needed:— 

a.  A  No.  8  catheter  to  which  is  attached  a  small  glass  tube. 
To  the  end  of  this  a  small  piece  of  rubber  tubing  is  attached 
and  into  this  a  glass  funnel  is  inserted. 

b.  A  towel  to  place  around  the  patient. 

c.  Lubricant. 

d.  Liquid  food  in  a  pitcher. 

2.  Technique: — 

a.  Oil  the  tube  and  insert  into  the  nostril,  passing  it  back- 
ward thru  the  posterior  nares  into  the  upper  part  of  the  phar- 
ynx.    If  it  is  passed  farther  it  should  be  pushed  on  down  into 
oesophagus.     If  the  catheter   enters  the  trachea  the  patient 
coughs,  can  not  breathe,  and  becomes  cyanotic.    After  the  tube 
is  in  place,  be  sure  that  the  patient  breathes  normally. 

b.  When  the  tube  is  in  place,  pour  the  food  down  and  remove 
the  tube  quickly,  pinching  it  as  near  the  nose  as  possible. 

c.  The  tube  is  then  cleaned,  using  the  same  method  as  for 
lavage  tubes. 

The  Nutrient  Enema 

In  various  gastric  disturbances  the  digestion  of  the  food  is 
so  imperfect  that  the  body  is  poorly  nourished,  so  that  it  be- 
comes necessary  to  supply  the  needed  nutriment  by  other  avenues 
than  the  mouth,  one  of  these  being  per  rectum  by  means  of  the 
nutrient  enema.  This  may  also  be  resorted  to  in  obstructive 
conditions  of  the  oesophagus  or  where  it  is  desired  to  give  the 
stomach  rest  for  a  time. 

1.  Preparation  of  the  patient.     Before  giving  the  nutrient 
enema  a  thoro  cleansing  enema  should  be  given  as  absorption 
takes  place  much  more  rapidly  when  the  lower  bowel  contains 
no  residue.     If  the  nutritive  enema  is  given  frequently,   as  a 
rule,  the  cleansing  enema  is  necessary  only  once  or  twice  daily. 

2.  Technique.     The  nutrient  enema  may  be  given  with  the 
patient  in  either  the  dorsal,  the  right  Sim's,  or  the  knee  chest 
position.     However,  if  the  patient  is  able  to  take  the  knee  chest 
position,  this  is  preferred. 

The  liquid  for  injection  is  then  prepared  by  the  nurse  ac- 
cording to  the  prescribed  formula. 


SO  GENERAL  NURSING 

The  following  articles  are  needed  for  the  administration  of 
a  nutrient  enema:  Colon  tube,  in  the  end  of  which  a  glass  fun- 
nel has  been  inserted,  a  small  pitcher  containing  the  liquid  to 
be  injected,  lubricant,  bed  sheet,  newspaper  or  rubber  sheet, 
towel. 

The  liquid  should  be  given  at  a  temperature  of  100°  F.  If 
the  enema  is  to  be  given  in  the  knee  chest  position,  place  the 
newspaper  or  rubber  sheet,  covered  with  a  towel,  under  the 
knees  of  the  patient.  Next  drape  the  hips  and  thighs  in  a 
sheet  for  protection  from  unnecessary  exposure.  The  sheet  is 
held  lengthwise,  grasped  in  the  center  and  this  point  placed  on 
the  sacrum,  each  half  being  used  to  cover  a  limb.  Next  lubri- 
cate the  tube  and  insert  it  not  more  than  four  inches.  Pour  the 
liquid  into  the  funnel.  After  the  liquid  has  passed  into  the 
bowel,  leave  the  colon  tube  in  place  a  few  moments,  then  slowly 
remove,  pinching  the  end  next  to  the  patient,  in  order  to  avoid 
the  expelling  of  any  of  the  fluid.  Assist  the  patient  to  the  re- 
cumbent position. 

If  there  is  an  intense  desire  to  eject  the  fluid,  hold  a  com- 
press over  the  rectum,  making  heavy  pressure  with  the  fist. 
This,  as  a  rule,  will  be  effective. 

Oftentimes  a  patient  can  not  take  the  knee-chest  position, 
and  experience  has  shown  us  that  with  some  people  the  fluid  is 
injected  with  difficulty  in  the  other  two  positions.  In  such 
cases,  the  following  may  be  used  with  success. 

Take  a  2-ounce  glass  syringe,  a  colon  tube,  and  a  pair  of 
artery  forceps.  Lubricate  the  colon  tube  and  insert  as  before. 
Fill  the  glass  syringe  and  insert  into  the  colon  tube,  forcing  the 
fluid  thru  it  by  pressure  on  the  piston  of  the  syringe.  Before 
removing  the  syringe  to  refill,  clasp  the  tube  with  the  forceps 
as  soon  as  the  syringe  is  placed  in  the  end  of  the  tube.  When 
all  the  fluid  has  been  injected,  remove  the  tube  as  usual. 

3.  Formulae.  As  a  rule  the  physician  prescribes  the  for- 
mula for  the  nutrient  enema.  The  following  are  given  as  ex- 
amples:— 

I.     Milk  5  iv. 
1  beaten  egg. 
8  gr.  of  salt. 

II.  The  whites  of  2  eggs. 
Peptonized  milk  3  ij. 
8  gr.  of  salt. 


POULTICES  AND  CATAPLASMS  31 

III.  Malted  milk  broth  3  iv. 
1  beaten  egg. 

8  gr.  of  salt. 

IV.  Thin  barley  gruel  (thoroly  cooked)  3  vi. 
1  beaten  egg. 

8  gr.  of  salt. 

Poultices  or  Cataplasms 

1.  Purpose:— 

a.  To  make  application  of  moist  heat. 

b.  To  produce  counter  irritation. 

2.  Items  to  be  observed:— 

a.  A  poultice  should  not  be  removed  until  a  fresh  one  is  ready 
to  apply.     Always  wipe  the  part  dry  before  placing  the  poultice. 

b.  Poultices  must  be  freshly  made  each  time  they  are  needed. 

c.  The  poultice  should  be  covered  with  flannel  and  rubber 
cloth  or  oiled  silk  in  order  to  retain  the  heat  and  keep  the  pa- 
tient dry. 

d.  The  spreading  of  the  poultice  is  facilitated  by  the  use  of  a 
thin  piece  of  board— a  poultice  board— upon  which  the  cloth  is 
laid. 

e.  A  poultice  should  be  applied  as  hot  as  the  patient  can  stand. 

f.  It  should  never  be  left  on  until  cold. 

g.  Oil  the  skin  before  applying  a  poultice. 

h.  Take  a  piece  of  muslin  twice  the  length  of  the  poultice. 

i.  On  one  half  spread  the  poultice  ingredients  leaving  a  mar- 
gin of  1  1/2  inches. 

j.  Fold  the  other  half  over  as  a  cover,  turning  the  edges  in. 

k.  Fold  in  a  compress  cloth  or  towel  and  carry  to  the  patient 
on  a  rubber  bag  filled  with  hot  water. 

Flaxseed  poultice.  Stir  the  meal  little  by  little  into  boiling 
water.  When  of  the  consistency  of  mush,  remove  from  the 
stove,  beat  well  and  spread  about  1/2  inch  thick  on  muslin  and 
apply  in  the  usual  way. 

Mustard  poultice,  a.  Make  a  flaxseed  poultice  as  usual. 
Take  of  mustard  1/8  to  1/4  of  the  amount  of  meal  used,  make 
into  a  thick  paste  and  stir  this  into  the  linseed  that  has  been 
prepared  for  the  poultice. 

b.  Mix  together  1  part  flour  and  2  parts  mustard.     Moisten 
with  water  and  add  a  small  amount  of  oil. 


32  GENERAL  NURSING 

c.  White  of  one  egg  lightly  beaten.  Add  sufficient  mustard 
to  make  of  proper  consistency.  If  a  very  mild  effect  is  desired, 
use  mustard  and  flour  equal  parts,  with  the  white  of  egg.  For 
an  infant  use  1  part  of  mustard  to  12  parts  of  flour. 

Spice  poultice:— 

Ginger  5  ij. 

Clover  5  ij. 

Cayenne  Pepper  5  j. 

Flour  5  ss. 

Sufficient  water  to  make  a  paste. 
Spread  between  two  layers  of  muslin. 

Glycerin  and  clay  poultice.  This  is  sold  under  various 
trade  names,  such  as  antiphlogistine,  anti-thermoline,  anti- 
itis.  Heat  and  spread  about  1/2  inch  thick  on  a  muslin  cloth 
cut  to  fit  the  part.  Over  this  place  thin  gauze.  Apply  the 
gauze  side  to  the  part  affected.  Cover  with  a  pad  made  of 
cotton  enveloped  with  gauze.  This  cotton  pad  can  generally 
be  used  several  times. 

Clay  jacket.  Take  two  pieces  of  muslin.  Cut  to  fit  the 
anterior  and  posterior  area  of  the  upper  trunk.  Spread  on  the 
antiphlogistine  as  directed  above  and  also  the  gauze.  Apply  to 
the  surface  and  over  this  fit  a  jacket  of  cotton. 

Diet 

In  such  an  outline  as  this  only  a  few  general  items  can  be 
given  on  diet,  as  this  subject  is  a  broad  one  and  is  always  taken 
up  as  a  branch  by  itself.  Special  diets  are  often  prescribed  for 
patients,  and  the  general  significance  of  the  terms  used  to  de- 
scribe them  should  be  understood  by  the  nurse. 

SPECIAL  DIETS 

1.  Fruit  diet.  In  following  a  fruit  diet  the  nutriment  given 
the  patient  is  very  much  reduced,  while  at  the  same  time  the 
stomach  is  not  put  at  complete  rest;  so  that  it  is  frequently  bet- 
ter than  a  total  fast,  especially  as  it  furnishes  a  residue  which 
helps  to  prevent  constipation.  The  sugars  of  the  fruit  do  fur- 
nish some  energy  and  are  also  laxative.  It  is  well  to  administer 
only  one  or  two  kinds  at  a  meal;  a  variety,  however,  may  be 
allowed  over  several  meals. 


DIET  33 

2.  Liquid  diet.     Gruels,   broths,  soups,  egg  nogg,    beaten 
white  or  whole  of  the  egg,  curdled  egg,  milk,  cream,  butter  milk, 
clotted  milk,  Yogurt,  malt  honey,  thin  vegetable  gelatin  (agar- 
agar),  frozen  cream,  fruit  juices,  albumin  water. 

3.  Soft  or  semi-solid  diet.     Eggs,  raw,  soft  or  boiled;  jel- 
lied egg,  custards,  soft  toasts,  cereals,  flaked  cereals,  corn  pulp, 
purees,  stewed  fruits. 

4.  Solid  diet.     The  articles  allowed  in  solid  diet  are  those 
usually  allowed  when  a  general  diet  is  prescribed.     In  selecting 
foods  for  a  general  diet  care  should  be  taken  about  combina- 
tions. 

5.  Dry   diet.     The  articles  constituting  this  diet  are  fre- 
quently ordered  in  cases  of  defective  digestion,   particularly 
where  the  hydrochloric  acid  is  low  in  amount  and  also  for  the 
purpose  of  encouraging  thoro  mastication.     The  following  arti- 
cles may  be  included  in  this  diet:— 

Dextrinized  grains,  zwieback,  thoroly  toasted  bread,  toasted 
crackers,  granola,  corn  breads,  baked  potatoes,  popped  corn, 
puffed  rice  and  wheat  berries,  bananas,  steamed  figs,  hard 
boiled  yolk  of  eggs,  baked  apples,  butter,  and  in  some  cases 
fresh  nuts  and  nut  foods  may  be  allowed. 

DIETS  FOR  SPECIAL  DISEASES 

1.  Constipation.     Fresh  fruits,   stewed  fruits,  stewed  rais- 
ins,  steamed   figs,   fruit  juices  except  blackberry,   lemonade, 
stewed  prunes,  flaked  foods,  buttermilk,  Yogurt,  graham  gems, 
bran  crackers,  gems  or  mush;  butter,  olive  oil,  ripe  olives,  malt 
honey,  most  nuts,   Irish  potatoes,   sweet  potatoes,  peas  purree, 
spinach  and  other  greens,  all  fresh  green  vegetables,  graham 
bread,  whole-wheat  bread,  coarse  vegetables,  berries. 

2.  Diarrhea.     Hot  boiled  milk,   brown  flour  gruel,  arrow 
root  or  gluten  gruel,   albumin  water,   soft  poached  or  curdled 
egg,  rice,  corn  starch,  toasted  white  bread. 

3.  Hypochlorhydria.     Dextrinized  cereals,  baked  potatoes, 
fresh  nuts  sparingly,    soft  cooked  eggs,    hard-boiled  yolk  of 
eggs,   fruit  of  all  sorts,   grapefruit  or  orange  before  the  meal, 
Yogurt,  fresh  green  vegetables,  peas  puree. 

4.  Hyperchlorhydria.     This  condition  is  especially  benefit- 
3 


S4  GENERAL  NURSING 

ted  by  the  use  of  free  or  emulsified  oils  such  as  olive  oil,  cotton 
seed  oil,  milk,  cream,  and  unsalted  butter;  gluten  gruel,  eggs, 
dextrinized  cereals,  nuts  and  nut  foods  very  sparingly,  sub-acid 
fruits  such  as  pears,  baked  apples,  prunes,  etc. 

5.  Diabetes.    Avoid  all  starches  especially  those  not  thoroly 
cooked.    Avoid  sugar.    The  following  articles  may  be  allowed:  — 

Baked  potatoes,  nuts  except  the  peanut  and  chestnut,  nut 
foods,  butter,  cream,  fresh  green  vegetables,  greens,  gluten 
breads,  baked  apples,  grapefruit,  lemons,  strawberries,  huckle- 
berries, buttermilk,  Yogurt,  eggs,  cauliflower,  turnips,  celery, 
cabbage,  lettuce,  radishes,  cucumbers,  egg  plant,  tomatoes, 
Jerusalem  artichokes,  Okra. 

6.  Bright' s  disease.    Dextrinized  cereals,  soups,  broths  and 
gruels,  rice,  flaked  cereals,  zwieback,  toasts,  milk,  cream,  but- 
ter, olive  oil,  fresh  green  vegetables,  fruits  of  all  kinds.     Avoid 
the  following:   Meats,  nut  foods,  eggs,  gluten,   and  all  other 
heavily  proteid  foods. 

7.  Fevers.     In  fevers  the  diet  will  vary  according  to  the 
nature  of  the  fever  and  its  duration.     Broths,  strained  soups 
and  gruels,  albumin  water,  fruit  juices,   soft  pulp  of  fruit,  but- 
termilk, cereal  waters,  egg  noggs. 

RULES  FOR  EATING 

1.  Masticate  the  food  thoroly. 

2.  Avoid  over  eating. 

3.  Eat  slowly. 

4.  Do  not  wash  the  food  down  with  a  beverage. 

5.  Do  not  drink  freely  at  meals. 

6.  Make  the  meal  hour  a  pleasant  one. 

7.  Do  not  worry  over  the  food  eaten  or  watch  for  unpleas- 
ant symptoms  to  develop. 

8.  Do  not  eat  when  fatigued  or  worried. 

9.  Remember  "a  merry  heart  doeth  good  like  a  medicine." 

FOOD  COMBINATIONS 

Persons  having  digestive  disturbances  frequently  find  it 
impossible  to  take  foods  in  certain  combinations.  Unless  the 
digestion  is  very  good  there  are  certain  combinations  which 
should  be  avoided. 


ADMINISTRATION  OF  MEDICINES  35 

1.  Good  combinations:— 

Cereals  and  nuts. 
Cereals  and  milk. 
Cereals  and  fruit. 
Cereals  and  eggs. 
Cereals  and  vegetables. 
Cereals,  milk  and  eggs. 
Fruit  and  nuts. 
Sub-acid  fruit  and  cream. 

2.  Bad  combinations: — 

Fruits  and  vegetables. 
Acid  fruit  and  milk. 
Milk  and  sugar. 

Administration  of  Medicines 

METHODS  OF  INTRODUCING  INTO  SYSTEM 

1.  Stomach.     When  given  in  this  way  drugs  take  effect  in 
about  20  minutes.     They  are  absorbed  more  quickly  when  given 
on  an  empty  stomach. 

2.  Rectum.     The  drug  is  absorbed  in  about  3/4  hour. 

3.  Cellular  tissue  (subcutaneous),  i.  e.,  by  hypodermic.  The 
effect  of  the  drug  is  evident  in  about  five  minutes. 

4.  Skin  by  inunction. 

5.  Lungs  by  inhalation. 

Sometimes  a  drug  produces  symptoms  that  are  very  dif- 
ferent from  the  ordinary.  Patients  manifesting  such  a  pecu- 
liarity are  said  to  have  an  idiosyncrasy  for  the  drug  in  question. 

Some  drugs  have  a  "cumulative  action, "  i.  e.,  the  excretion 
of  the  drug  is  so  slow,  that  one  dose  is  not  entirely  excreted 
before  another  is  taken.  The  drug  thus  accumulates,  and  after 
a  time  symptoms  of  poisoning  may  develop  thru  the  cumulative 
action. 

PRECAUTIONS  IN  HANDLING  AND  ADMINISTRATION  OF  MEDICINES 

1.  All  medicines  must  be  kept  out  of  the  reach  of  children 
and  delirious  patients. 

2.  The  label  and  directions  should  be  read  three  times  be- 
fore giving  the  medicine. 

3.  See  that  the  relief  nurse  thoroly  understands  the  direc- 
tions in  regard  to  the  medicine  to  be  given  the  patient. 


36  GENERAL  NURSING 

4.  Medicine  glasses  and  spoons  must  be   thoroly  washed 
after  being  used.     Separate  ones  should  be  kept  for  strong 
smelling  medicine  and  oils. 

5.  When  ordered  before  meals  medicines  should  be  given 
one-half  hour  before,   and  those  to  be  given  after  meals  should 
be  given  one-half  hour  after,  unless  otherwise  ordered. 

6.  An  unconscious  patient  should  have  the  medicine  dropped 
far  back  on  the  tongue  in  order  to  compel  swallowing. 

7.  Do  not  give  powders  by  mouth  to  an  unconscious  pa- 
tient, as  they  may  cause  suffocation. 

Powders.  1.  Generally  given  dry  on  the  tongue  and  fol- 
lowed by  a  drink  of  water. 

2.  They  may  be  dissolved  in  water  or  milk. 

3.  Powders  that  are  bitter  may  be  enclosed  in  capsules  or 
wafers.     The  latter  may  be  secured  from  any  druggist.     One 
is  moistened,  the  powder  put  in  its  center,  another  wafer  is  laid 
over  this  and  the  two  are  pressed  firmly  together.     Place  on  the 
tongue  and  swallow  by  drinking  water. 

Pills.  Place  on  the  back  part  of  the  tongue  and  swallow 
with  water.  For  children  who  find  it  difficult  to  swallow  a  pill, 
it  may  be  crushed  and  mixed  with  honey. 

Acids.  These  injure  the  teeth  and  so  should  be  taken  thru 
a  glass  tube  and  the  mouth  thoroly  rinsed  after. 

Oils.  These  may  be  taken  in  cereal  coffee,  milk,  lemon 
juice,  or  orange  juice. 

Suppositories.  These  are  drugs  incorporated  in  cacao  but- 
ter or  other  semi-solid  substance  and  made  up  into  conical 
shapes  for  convenient  introduction  into  the  rectum  or  vagina. 
To  place  in  the  rectum  oil  the  suppository  and  finger.  Insert 
the  suppository  and  push  well  up  into  the  rectum  until  it  can 
not  be  felt  by  the  finger.  Place  a  napkin  over  the  anus  and 
apply  pressure  to  part  until  the  desire  to  expel  the  suppository 
has  passed. 

Inhalations.  The  administration  of  drugs  in  the  form  of 
a  vapor,  or  nebula  (cloud). 

INCOMPATIBILITIES 

When  medicines  do  not  combine  well  or  have  opposite  ef- 
fects, they  are  said  to  be  incompatible.  There  are  three  kinds 
of  incompatibility — chemical,  pharmaceutical,  and  physiologic. 


FULL  EXAMINATION  37 

Chemical  incompatibilities.  Medicines  which  react  upon 
each  other,  producing  a  new  chemical  substance.  This  is  illus- 
trated in  the  combining  of  acids  and  alkalies,  such  as  hydro- 
chloric acid  and  bicarbonate  of  soda  which  form  common  salt.  < 

Pharmaceutical.  Substances  that  do  not  mix  well  mechani- 
cally or  do  not  dissolve  in  each  other,  such  as  oil  and  water. 

Physiologic.  When  the  effect  of  one  drug  neutralizes  that 
of  another  they  are  said  to  be  physiologically  incompatible;  for 
example,  morphine  and  strychnin. 

A  medicine  ordered  in  minims  must  not  be  measured  by 
drops.  Use  the  minim  glass. 

Full  Examination 

1.  Articles  to  be  in  readiness:— 

a.  2  large  sheets.  e.  Lubricant. 

b.  2  towels.  f.  Pitcher  of  drinking  water 

c.  1  napkin.  and  a  glass. 

d.  Basin  of  warm  water  and  g.  Waste  basket. 

soap. 

2.  Instruments  for  examination.     These  should  be  warmed 
before  using. 

|  Sim's  or  modified  Sim's. 

a.  Speculum giv^e- 

1  Rectal. 

I  Others  as  case  may  require. 

b.  Dressing  forceps. 

c.  Spatula. 

d.  Applicator. 

e.  Stethoscope. 

f.  Tampons  and  absorbent  cotton. 

3.  Full  examination  in  office.     Remove  all  clothing.     Have 
sheet  folded  lengthwise  and  placed  around  the  patient's  shoul- 
ders, and  another  sheet  for  the  lower  limbs. 

4.  Pelvic  examination.     Place  the  patient  on  the  table  in 
the  dorsal  position.    Take  a  second  sheet,  place  over  the  patient 
so  that  the  center  fold  comes  to  the  center  of  the  table  between 
the  lower  limbs.     Pull  the  sheet  down  leaving  only  enough  to 
cover  abdomen.     Begin  at  crease  in  center  of  sheet,  gather  up 
in  folds,  and  push  well  up  over  abdomen.     Take  inside  corners 
and  push  well  up  under  hips  until  it  fits  snugly  around  inside  of 


88  GENERAL  NURSING 

thighs  in  such  a  way  as  not  to  expose  the  patient  in  any  way. 
Outside  corners  should  be  folded  around  the  feet  so  as  to  give 
a  neat  appearance,  and  the  patient  will  not  feel  that  she  is  un- 
necessarily exposed. 

Be  sure  that  the  patient  is  well  down  on  the  tafre  and  that 
there  is  a  fresh  folded  napkin  under  the  hips,  covering  the  edge 
of  the  table. 

For  a_pelvic  examination  only,  it  is  not  necessary  to  remove 
the  clothing  except  closed  drawers,  which  should  be  removed. 
In  all  cases,  be  sure  that  all  bands  about  the  waist  are  loosened. 
Place  in  dorsal  posit'on  as  for  full  examination. 

Vaginal  speculum  examination.  A  Sim's  speculum,  dres- 
sing forceps,  lubricant,  and  five  or  six  tampons  should  be  at 
hand.  The  table  should  be  so  placed  that  the  light  will  fall 
directly  into  the  speculum.  In  assisting  the  physician,  be  sure 
that  you  stand  where  you  will  not  interrupt  the  light.  In  hand- 
ling the  tampons  to  the  physician,  catch  the  cord  close  to  the 
last  tampon  so  that  the  physician  may  easily  grasp  with  for- 
ceps. If  the  other  hand  is  free  the  nurse  may  catch  the  free 
end  of  the  cord  so  that  it  may  not  become  entangled  around  the 
tampon. 

5.  External  examination   of  abdomen.     Separate   the   two 
sheets  so  that  the  abdomen  is  exposed. 

6.  Examination  of  heart  and  lungs  in  the  sitting  posture. 
Have  the  patient  sit  on  the  end  of  the  table  with  the  feet  rest- 
ing on  a  stool.     Place  a  sheet  about  the  shoulders.     Hand  the 
stethoscope  to  the  physician. 

7.  Rectal  examination.     Place  on  the  table  in  the  Sim's  po- 
sition.    Adjust  the  sheet  in  the  same  way  as  for  the  dorsal  po- 
sition,  except  that  center  fold  is  at  the  back  instead  of  the 
front.     Fold  the  upper  corner  of  the  sheet  around  the  right 
limb  in  such   a  way  that  the  clothing  and  limbs  are  entirely 
covered.     The  nurse  should  stand  at  the  back  of  the  patient  and 
place  her  hands  one  on  either  side  of  the  rectum  and  separate 
the  buttocks  in  such  a  way  that  the  physician  can  insert  the 
speculum. 

8.  Knee-chest  or  genu-pectoral  position.     Place  the  patient 
on  the  knees  with  the  hips  elevated  and  chest  brought  as  close 
to  the  table  as  possible.    Place  the  sheet  so  that  the  center  fold 
is  at  the  sacrum.     Adjust  it  as  in  the  dorsal  position. 


CARE  OF  THE  DEAD  3$ 

9.  Examination  in  bed.  a.  If  digital  examination,  place 
patient  on  the  side  of  bed  in  the  dorsal  position;  sheet  and  nap- 
kin are  adjusted  same  as  on  a  table  in  an  office. 

b.  Speculum  examination  in  bed.  Place  the  patient  crosswise 
of  the  bed  in  the  dorsal  position,  drawing  hips  well  down  to  the 
edge  of  the  bed.  Place  a  fresh  napkin  over  edge  of  the  bed  for 
protection.  Adjust  the  sheet  the  same  as  in  the  dorsal  position 
on  a  table,  being  sure  to  keep  the  feet  well  covered.  The  list 
of  instruments  is  the  same  as  for  speculum  examination  in  an 
office.  Be  sure  to  have  the  bed  in  position  to  give  the  best  light 
possible. 

The  Care  of  the  Dead 

If  there  are  signs  of  death  notify  the  physician  at  once. 
Never  take  the  responsibility  of  being  along  with  a  dying  pa- 
tient. 

1.  Cool  the  room  and  remove  all  surplus  of  bedding  at  once. 

2.  Straighten  limbs  and  close  eyes.    Place  a  shred  of  cotton 
under  the  eyelid  to  keep  it  in  proper  place. 

3.  Pack  the  nostrils,  mouth,  back  part  of  nose,  rectum  and 
vagina  with  common  cotton  in  order  to  prevent  the  escape  of 
post-mortem  discharges. 

4.  Replace  false  teeth  as  soon  as  the  mouth  is  packed. 

5.  Place  a  support  under  the  chin. 

6.  Wash  the  body  with  soap  and  water.     If  the  case  is  in- 
fectious,   wash   in   2  1/2%    carbolic   solution   and  wrap   in   a 
sheet  wrung  from  5%  carbolic  solution. 

7.  If  there  are  any  wounds,  do  not  touch  bandage  without 
instruction  from  physician  or  head  nurse. 

8.  Place  a  triangular  bandage  around  the  hips,  laying  over 
the  rectum  a  layer  of  cotton  and  some  salt. 

9.  Manicure  the  nails  and  comb  the  hair. 

10.  Bandage  the  knees  together.     Place  stockings  on  the 
feet  and  put  on  a  simple  nightgown. 

11.  Roll  a  small  pillow  and  place  under  the  hands.     Also 
bandage  the  arms  together  across  the  chest. 

12.  Put  a  clean  sheet  on  the  stretcher  and  then  the  body. 
Elevate  the  head  of  the  stretcher  at  least  one  foot. 

13.  Put  a  clean  sheet  over  the  body  and  remove  all  traces  of 
death  from  the  room. 


40  GENERAL  NURSING 

14.  Pack  the  belongings  of  the  patient  so  that  they  can  be 
taken  with  the  body. 

15.  Leave  the  room  in  order. 

16.  After  the  body  is  removed,    fumigate  the  room  if  the 
case  has  been  infectious  and  the  next  morning  return  all  sup- 
plies that  belong  to  the  medical  department.    See  that  they  are 
all  clean  and  ready  for  use. 

CONTENTS   OF   DEATH   BASKET 

Two  sheets.  Common  Cotton. 

Two  turkish  towels.  Disinfectant. 

Two  toilet  towels.  Safety  pins — medium. 

Bandages  for  hands  and  knees.        Nail  cleaner. 

Small  pillow.  Scissors. 

Support  for  chin.  Dressing  forceps. 

Large  triangular  bandage.  Comb. 

Salt. 


SPECIAL  CONDITIONS  AND  EMERGENCIES 

General  Care  of  Infectious  Cases 

An  infectious  disease  is  one  that  is  produced  by  the  growth 
of  pathogenic  microbes  in  the  body  or  on  its  surface.  A  con- 
tagious disease  is  an  infectious  disease  that  may  be  contracted 
without  immediate  contact  with  the  patient. 

All  infectious  diseases  are  caused  by  specific  germs.  Care- 
lessness on  the  part  of  the  nurse  may  result  in  untold  harm,  as 
success  depends  on  diligent  attention  to  minute  details. 

1.  Isolate  the  patient. 

2.  Room:— 

a.  Location — upper  part  of  house;  south  and  south-east,  or 
south  and  south-west  exposure  preferred. 

b.  Remove  rugs,  draperies,  and  all  unnecessary  furniture. 

c.  Wipe  woodwork  and  floor  twice  a  day  with  2%  carbolic  or 
1—1000  HgCb  solution. 

d.  When  there  is  dust,  germs  are  always  present,  so  regard 
dust  as  a  deadly  foe.    The  broom  may  be  covered  with  dust  bag 
dipped  in  3%   carbolic.     If  possible,  have  two  rooms,   keeping 
the  patient  in  one  room  during  the  day  and  the  other  at  night. 

3.  Linen. — Disinfect  all  linen  by  soaking  in  5%  carbolic, 
2r/f  formaldehyde,  or  any  reliable  disinfectant  for  at  least  one 
hour.     Wrap  the  disinfected  linen  in  a  sheet  wrung  from  the 
same  solution.     This  clothing  should  be  boiled  within  one  hour 
after  leaving  the  room. 

4.  Waste  basket. — It  is  very  convenient  in  the  care  of  in- 
fectious cases  to  have  a  stove  in  the  room.     Thus  all  waste  ma- 
terial ^an  be  burned.     Otherwise- wrap  the  contents  of  the  waste 
basket  in  a  paper,  then  dip  in  disinfectant  solution  and  dispose 
of  as  quickly  as  possible.     If  in  a  private  home  arrangements 
can  be  made  for  some  member  of  the  family  to  get  this  at  a 
certain  time  each  day  and  burn  as  soon  as  possible. 

5.  Dishes. —Outside  of  the  door  there  should  be  a  small 
table  which  the  nurse  will  find  useful  in  many  ways.    All  dishes 


42  GENERAL  NURSING 

should  be  soaked,  for  one  hour  in  5%  carbolic,  or  better  still, 
boiled  for  1/2  hour,  then  placed  on  the  table  outside  of  the  door 
for  some  member  of  family  to  get.  A  sheet  wrung*  from  the 
disinfectant  solution  should  be  hung  outside  the  door  and  kept 
wet. 

6.  Discharges. — Disinfect  with  chloride  of  lime  or  carbolic 
acid,  and  let  stand  one  hour.    All  water  used  in  the  room  should 
be  disinfected  before  being  emptied. 

7.  Nurse.  — Wear  a  surgical  gown  with  cap  of  gauze  over 
the  hair.     If  not  on  24-hour  duty,  before  leaving  the  room  the 
gown  should  be  removed,  hands  disinfected  and  the  uniform  put 
on  outside  in  a  small  room  or  closet  reserved  for  the  purpose. 

Never  touch  the  face,  hair,  or  lips  without  first  disinfecting 
the  hands.  The  care  of  different  infectious  diseases  varies  con- 
siderably and  the  special  care  of  each  will  be  carefully  studied 
in  the  course  on  diseases.  If  possible,  take  a  walk  in  the  fresh 
air  every  day. 

8.  Before  going  into  quarantine  the  nurse  must  not  forget 
to  select  and  have  taken  to  the  isolation  quarters  all  articles 
that  will  be  needed. 

Suggestive  list:  — 

Bedding.  Pails. 

Clothing  for  patient.  Whisk  broom. 

Towels.  Tub. 

Disinfectants.  Measuring  glasses. 

Soap.  Treatment  articles. 

Broom.  Charts — pen  and  ink. 
Dust  pan. 

9.  Allow  nothing  to  go  from  the  sick  room  without  being 
thoroly  disinfected. 

10.  How  to  close  a  quarantine. 
Patient:— 

a.  Thoro  bath  of  soap  and  water  and  hair  shampoo. 

b.  Wrap  the  patient  in  a  clean  sheet  and  blanket  and  take  to 
another  room  previously  prepared.     Provide  the  patient  with 
clean  clothing. 

Room: —  . 
a.  Mattress,  pillows  and  blankets  are  removed  and  placed  so 


BED  SORES  43 

that  the  fumes  of  the  disinfectant  can  find  an  easy  access  to 
all  parts. 

b.  All  drawers,  closets,  and  cupboards  in  the  room  should  be 
left  open. 

c.  Cracks  around  the  room  are  sealed  to  prevent  escape  of 
the  fumes. 

d.  Rooms  may  be  disinfected  with  formaldehyde  or  sulphur. 

Formaldehyde  disinfection.  Formula  for  1000  cu.  ft.  of 
space:  Place  newspapers  on  the  floor  covering  a  large  space. 
In  the  center  of  this  place  a  large  pail  containing  8  oz.  of 
permanganate  crystals.  When  everything  is  ready  pour  over 
the  crystals  20  oz.  of  formalin  and  make  a  rapid  exit,  sealing 
the  door  and  keyhole  from  the  outside.  Formaldehyde  gas  does 
not  tarnish  or  bleach  articles. 

Sulphur  disinfection.  This  is  not  considered  reliable  but 
may  be  used  if  nothing  else  is  available.  Required,  4  Ibs.  of 
sulphur  for  every  1000  cu.  ft.  of  space.  Place  the  sulphur  in  a 
pan  which  is  set  upon  several  bricks  in  a  tub  containing  water 
enough  to  cover  them,  the  water  being  provided  to  avoid  danger 
of  fire  from  the  burning  sulphur.  A  liberal  quantity  of  alcohol 
is  then  poured  over  the  sulphur,  and  at  the  last  moment  before 
leaving  the  room  a  lighted  match  is  applied,  great  care  being 
necessary  to  stand  well  back  from  the  pan  and  to  avoid  inhaling 
the  sudden  rise  of  fumes.  Leave  24  hours. 

The  next  day  after  fumigation  when  entering  the  room  to 
open  windows,  take  the  precaution  of  covering  the  mouth  and 
nose  with  a  damp  towel. 

e.  All  infected  dishes  should  be  boiled  10  minutes. 

f.  Infected  linen  is  put  to  soak  in  carbolic  acid  solution  1-20. 

Nurse.  Take  a  bath  and  hair  shampoo.  Put  on  clean  clothes 
in  another  apartment.  All  clothing  and  outfit  exposed  to  infec- 
tion are  left  behind  to  be  disinfected  or  fumigated. 

Bed  Sores 

A  nurse  should  guard  against  bed  sores.  They  can  usually 
be  avoided.  An  exception  to  this  may  be  found  in  the  following 
conditions:  — 

1.  Edema. 

2.  Paralysis. 


44  GENERAL  NURSING 

3.  Spinal  injuries. 

4.  Continuous  discharge  from  any  part  of  the  body. 

As  a  rule,  the  development  of  a  bed  sore  gives  good  ground 
for  severe  criticism  of  a  nurse. 

The  first  evidence  to  the  patient  of  a  bed  sore  is  a  stinging 
sensation  and  a  feeling  as  if  he  were  lying  on  something  rough. 
The  nurse  should  never  wait  for  this  report  from  the  patient, 
but  should  watch  continually  and  inspect  daily  the  parts  liable 
to  be  affected. 

1.  Exciting  causes :- 

a.  Continuous  pressure. 

b.  Friction  between  two  surfaces. 

c.  Moisture. 

d.  Creases  in  under-sheet  or  night  gown  or  rubber  sheet. 

e.  Crumbs  in  the  bed. 

f.  Lack  of  proper  care  or  cleanliness. 

2.  Predisposing  causes:— 

a.  Malnutrition. 

b.  Fat,  flabby  condition  of  flesh. 

c.  Emaciation. 

d.  Poor  circulation. 

e.  Old  age. 

f.  Fevers. 

g.  Paralysis. 

h.  Long  confinement  in  recumbent  posture. 

i.  Edema. 

j.  Irritating  discharges. 

3.  Parts  susceptible:— 

a.  Hips,  lower  part  of  back,  shoulders,  heels.     In  these  loca- 
tions the  bed  sore  is  generally  caused  by  pressure. 

b.  Inner  surfaces  of  knees,  elbows,  back  of  head.     Generally 
due  to  friction. 

c.  Those  caused  by  malnutrition  may  appear  any  place  where 
there  is  undue  pressure.    Often  first  appear  in  the  form  of  pus- 
tules. 

4.  Preventive  measures:— 

a.  Absolute  cleanliness. 

b.  Removal  of  pressure. 

c.  Light  massage  to  parts. 


COMMON  EMERGENCIES  45 

d.  Rub  with  50%  alcohol. 

e.  Dust  with  powder. 

f.  Hot  and  cold  applications  may  be  given. 

g.  If  there  is  much  moisture  the  part  may  be  rubbed  with 
any  kind  of  oil. 

h.  Keep  the  bed  free  from  crumbs  and  wrinkles.     Make  it  a 
rule  to  brush  crumbs  out  of  the  bed  after  each  meal, 
i.  Place  soft  pads  where  there  is  friction. 

5.  Treatment.  Report  to  the  physician  and  follow  his  in- 
structions in  the  case.  If  left  to  use  your  own  judgment,  the 
following  measures  may  be  employed:  — 

a.  Hot  and  cold  applications. 

b.  Wash  with  weak  disinfectant  solution,  — 

Green  soap— 1%. 
HgCl2— 1—5000. 
Boracic  acid— sat.  sol. 
Carbolic— 1%. 

Fix  cresol — 1  tablet  to  four  ounces  of  water. 
Alcohol  95%,  alum — sat.  sol.,  or  picric  acid — sat.  aqueous 
sol. 

c.  Apply  a  soothing  ointment  (any  of  the  following  may  be 
used)  :— 

1.  Zinc  ointment. 

2.  Bismuth  ointment. 

d.  Apply  sterile  gauze  and  bandage. 


Common  Emergencies 

FAINTING 

If  one  feels  the  approach  of  a  fainting  attack,  it  is  a  good 
plan  to  bend  from  the  waist  lowering  the  head  as  far  as  pos- 
sible. This  position  sends  more  blood  to  the  brain. 

Treatment:— 

1.  The  head  lowered  and  feet  raised— the  blood  is  thus  sent 
back  to  the  brain. 

2.  Provide  abundance  of  fresh,  cool  air. 

3.  Loosen  clothing  about  neck,  chest  and  waist. 


46  GENERAL  NURSING 

4.  A  little  cold  water  dashed  in  face. 

5.  Smelling  salts. 

If  consciousness  does  not  soon  return,  external  warmth 
must  be  applied  and  a  physician  should  be  sent  for. 

To  distinguish  fainting  from  hysteria. — In  hysteria  the  pulse 
is  normal.  The  patient  resists  any  attempt  to  raise  the  eyelids. 
The  body  is  warm.  Practically  no  change  of  color  in  the  face. 

HYSTERIA 

Dismiss  the  friends  and  spectators,  as  nothing  is  so  con- 
ducive to  a  prolonged  and  severe  attack  as  an  audience. 

If  serious  symptoms  appear  suggestive  of  other  difficulties, 
send  for  the  physician.  Otherwise  use  such  simple  applications 
as  a  hot  foot  bath,  fomentations  to  abdomen  or  spine,  or  a  full 
warm  bath  to  produce  relaxation. 

Suggestion  is  an  efficient  method  of  controlling  attacks,  but 
this  and  governmental  methods  had  best  be  left  to  the  head 
nurse  or  physician  unless  definite  directions  are  given  the  nurse 
for  their  use. 

EPILEPSY 

Place  the  patient  on  the  ba^k  with  the  head  slightly  raised. 
Loosen  any  tight  clothing  and  see  that  he  does  not  hurt  himself. 
Provide  abundance  of  fresh  air.  Place  something  between  the 
teeth  to  keep  him  from  biting  the  tongue.  No  attempt  should 
be  made  to  stop  the  movements. 

DROWNING 

1.  Treatment,  if  the  patient  is  still  breathing  when  taken 
from  the  water:— 

Remove,  if  possible,  to  a  nearby  house  and  give  hot  bath, 
or  apply  heat  over  the  abdomen.  Rub  body  briskly. 

2.  To  restore  the  patient  when  life  is  apparently  gone:— 

a.  Loosen  clothing. 

b.  Open  mouth,  wipe  it  out. 

c.  Clear  throat  of  mucus. 

d.  Turn  patient  face  downward.     Have  the  abdomen  rest  on 
coat  or  shawl  folded.     Make   pressure   on   both  sides  of  the 
throat,  so  as  to  force  out  any  water  that  may  have  entered  the 
air  passages. 


COMMON  EMERGENCIES  47 

e.  Turn  on  back  again  and  give  artificial  respiration. 

f .  Wet  clothing  should  be  removed  as  soon  as  possible  and 
warm  blankets  and  bottles  placed  about  patient. 

g.  Alternate  hot  and  cold  applications  given  to  the  chest  are 
good  to  aid  in  stimulating  respiration. 

h.  Keep  up  the  artificial  respiration  for  an  hour  or  more  if 
necessary. 

SORDES 

"Collections  of  brown  or  black  material,  consisting  of  ac- 
cumulated debris  from  the  epithelial  layer  of  the  mucous  mem- 
brane of  the  mouth,  darkened  by  drying,  or  by  admixture  with 
blood  which  oozes  from  the  edges  of  the  gums,  form  upon  the 
teeth  and  lips  at  the  height  of  severe  cases  of  fever,  "i 

It  is  the  duty  of  the  nurse  to  keep  the  mouth  of  the  patient 
clean.  When  the  patient  is  helpless  and  not  able  to  assist  in 
this  procedure  the  nurse  takes  a  small  gauze  sponge,  or  small 
squares  of  soft  muslin,  wraps  it  about  the  finger,  dips  it  in  a 
good  mouth  wash  and  cleanses  the  teeth  and  mouth  thoroly.  If 
the  gums  are  not  too  sensitive,  instead  of  using  the  finger,  the 
artery  forceps  may  be  used  to  hold  the  sponge  or  cloth.  After 
this  cloth  is  used  it  is  dropped  onto  a  piece  of  papt  r  and  then 
others  used  until  the  mouth  is  thoroly  cleansed.  Then  the  pieces 
are  wrapped  in  the  paper  and  burned.  The  hands  should  then 
be  scrubbed.  Special  attention  should  be  given  to  the  mouth 
at  least  three  times  daily,  being  especially  careful  that  every 
part  of  the  cavity  is  gone  over. 

f  ormulae  for  Mouth  Washes 

I.  Lemon  juice  3j. 

Glycerine  Sj. 
II.  Carbolic  acid  5j. 

Listerine  3ij. 

M.  and  put  1  tsp.  in  a  1/3  of  glass  of  warm  water. 
III.  Essence  of  cinnamon  gtt.  x. 

Water  %  iv. 

CHILLS 

Stages  of,  - 

1.  Cold  shivering.     Apply  heat— hot  drinks. 


1  "Fever  Nursing,"  by  Dr.  J.  C.  Wilson. 


48  GENERAL  NURSING 

2.  Hoi— elevation  of  temperature.  Gradually  remove  heaters 
and  extra  coverings. 

3.  Perspiration.     Wipe  dry  and  avoid  chilling.     If  perspi- 
ration is  profuse  the  bed  and  body  linen  will  have  to  be  changed. 
Be  sure  that  fresh  linen  is  warmed. 


Poisons 

CLASSIFICATION:— 

1.  Irritants.     Those  which  burn  or  irritate  the  tissues. 

2.  Corrosives.     Those  which  destroy  the  tissues. 

3.  Neurotics.     Those  which  act  on  the  nervous  system. 

ANTIDOTES:— 

1.  Mechanical.     Those  which  remove  the  poison  entirely, 
prevent  its  action  by  dilution,  or  prevent  its  absorption. 

2.  Chemical.     Those  which  neutralize  the  poison  or  unite 
with  it  to  form  a  harmless  compound. 

3.  Physiological.      Those   which   counteract  the   effect  of 
poison  on  the  system. 

In  case  of  an  irritant  poison  give  an  emetic  or  lavage,  but 
where  a  corrosive  has  been  swallowed  there  is  danger  in  using 
this  method  as  perforation  of  the  stomach  or  oesophagus  may 
occur. 

Observe  the  following:  — 

1.  Burns  on  face,  hands,  lips,  etc. 

2.  Odor  of  breath. 

3.  Hemorrhage. 

4.  Nervous  twitching  of  face,  hands,  or  feet. 

5.  Rigidity. 

6.  Paralysis. 

7.  Urine,  if  any. 

Emetics:— 

1.  Common  salt  5i  in  Sviii  of  water. 

2.  Mustard  Sss  in  a  glass  of  water. 

3.  Syrup  of  Ipecac  5i  or  ij. 

4.  Zinc  sulphate  grs.  x— xxx  in  1/2  glass  water. 

5.  Apomorphine  1/10  gr.  by  hypodermic. 


COMMON  EMERGENCIES 


I.    IRRITANT  POISONS 


NAME 


SYMPTOMS 


ARSENIC 
Paris  green 
Scheele's  green 
Rough  on  rats 
Fowler's  solution 
Insect  powders 


Pain  in  esophagus  and 
stomach,  metallic  taste, 
nausea,  vomiting  and 
purging.  Often  bloody 
vomitus  and  fecal  mat- 
ter. Weak  pulse,  diffi- 
Donovan's  solution  cult  respiration,  great 
thirst,  swollen  face,  cold 
extremities,  cyanosis, 
convulsions,  coma,  and 
death, 


ANTIDOTES 


Evacuate  stomach  by  tube 
or  emetic.  Freshly  precipi- 
tated ferric  hydroxide  or 
ferric  hydroxide  with  mag- 
nesia. 

Stimulants,  artificial  heat. 


CHLORINE 

Chlorinated  lime 
Labarraque's  so- 
lution 
Javelle  water 


Inhaled,  causes  irrita- 
tion of  larynx  with 
edema  which  may  result 
in  asphyxia,  cough,  dif- 
ficult breathing,  and  dif- 
ficult swallowing.  Swal- 
lowed, produces  burning 
in  stomach.  May  per- 
forate. 


Get  patient  into  fresh  air, 
Empty  stomach  by  tube  or 
by  emetic  like  zinc  sulphate, 
mustard,  or  ipecac. 

Ammonia  gas  inhaled  or 
dilute  ammonia  by  mouth. 
Raw  white  of  egg. 

Stimulants,  strong  coffee. 


COPPER 
Copper  sulphate 

(blue  vitriol) 
Copper  acetate 

(verdigris) 
Copper  cooking 

utensils 


CROTON  OIL 


Metallic  taste,  pain  in 
abdomen  with  griping. 
Nausea  and  vomiting. 
Purging  of  green  mater- 
ial. Pulse  weak  and  ra- 
pid. Urine  diminished 
or  suppressed.  Coma. 

Severe  abdominal  pain, 
vomiting,  purging.  Pulse 
weak.  Skin  moist,  pros- 
tration, collapse,  death. 


Empty  stomach  with  tube, 
using  plenty  of  water.  Em- 
etic like  mustard  or  ipecac. 

Potassium  ferrocyanide, 
albumin,  milk. 


Empty  stomach  with  tube. 
Use  emetic  as  zinc  sulphate. 
Gum  arabic  or  white  of  egg, 
to  protect. 

Artificial  heat,  camphor, 
stimulants  for  heart. 


FORMALDEHYDE 

Formalin 


Inhaled. — Intense  irri- 
tation of  mucosae,  dys- 
pnoea, pain  in  head, 
sense  of  suffocation. 

Swallowed. — Pain, 
nausea,  vomiting,  dys- 
pnoea, vertigo,  rapid 
pulse,  urine  suppressed, 
collapse. 


Fresh  air,  stimulants. 
Ammonia,  apomorphin,  de- 
mulcents. 


IODINE 
Tincture  iodine 
Lugol's  solution 


Pain  in  throat  and 
stomach.  Metallic  taste, 
thirst,  vomiting,  purg- 
ing. Face  pale,  urine 
suppressed.  Pulse  weak 
and  rapid.  Cyanosis, 
excitement,  convul- 
sions, collapse. 


Empty  stomach,  demul- 
scents.  Starch  paste,  so- 
dium thiosulphate. 

Stimulants,  artificial  heat. 


50 


GENERAL  NURSING 


LEAD 

Sugar  of  lead 
White  lead 
Red  lead 
Goulard's  extract 


Dry  throat,  thirst, 
metallic  taste.  Pain  in 
abdomen,  cramps.  Nau- 
sea, vomiting.  May  be 
either  purging  or  consti- 
pation. Rapid,  weak 
pulse.  Convulsions, 
coma,  death.  In  chronic 
cases  blue  line  on  gums, 
wrist  drop,  lead  colic. 


Empty  stomach  by  tube. 

Soluble  sulphate,  such  as 
magnesium  sulphate  or  so- 
dium sulphate. 

Sulphur  baths,  potassium 
iodide,  electricity. 


MERCURY 
Bichloride 
Red  precipitate 
White  precipitate 


Gastro-enteritis,  me- 
tallic taste.  Salivation. 
Pain  in  throat,  esopha- 
gus, stomach.  Nausea 
and  vomiting,  purging. 
Bloody  stools.  Cold  ex- 
tremities, coma,  col- 
lapse, death. 

In  chronic  form,  line 
on  gums,  teeth  loose, 
tongue  swollen,  breath 
foul. 


Empty  stomach  if  vomit- 
ing has  not  occurred. 

White  of  one  egg  to  four 
grains  of  the  bichloride. 

Stimulants,  external  heat. 


PHOSPHORUS 

Matches 
Rat  poison 
Phosphorus  pills 


Odor  of  Phosphorus, 
garlic  taste  in  mouth. 
Burning  pain  in  stomach. 
Vomiting  of  luminous 
material.  Jaundice, 
headache,  dizziness, 
scanty  and  albuminous 
urine.  Convulsions, 
coma,  death.  Postmor- 
tem shows  fatty  degener- 
ation of  liver  and  other 
organs. 


Empty  stomach,  avoid  fats 
and  oils. 

Copper  sulphate,  potas- 
sium permanganate,  hydro- 
gen peroxide. 

Oxygen,  artificial  heat. 


PTOMAINS                     Variable.    Thirst,  nau-  Empty    stomach,     demul- 

sea,    vomiting;    convul-  scents.     Tannic  acid, 

sions  by  some,  sleep  by  Combat  symptoms  as  they 

others.  arise. 


SILVER 

Silver  nitrate 
Lunar  caustic 


Pain,  nausea,  and  vom- 
iting. Vomited  mater- 
ial turns  black  in  light. 
Purging,  dizziness,  con- 
vulsions, paralysis,  coma, 
collapse. 


Evacuate  stomach  by  tube 
or  emetic. 

Sodium  chloride  (common 
salt),  albumins. 

Stimulants,  external  heat. 


ZINC 

Zinc  sulphate 
Zinc  chloride 


Corrosion  of  lips  and 
mouth.  Pain  and  burn- 
ing in  digestive  tract. 
Vomiting  and  nausea. 
Convulsions,  paralysis, 

collapse. 


Empty  stomach  with  tube 
or  emetic  like  ipecac.  Albu- 
min, alkaline  carbonates. 
External  heat. 


COMMON  EMERGENCIES 
II.    CORROSIVES 


CARBOLIC  ACID         Pain    and    burning    in 
In  various  dilutions  mouth   and  stomach, 
and  full  strength.     Sometimes  vomiting, 
whitening    of    lips    and 
mouth.     Dyspnoea,    diz- 
ziness   and   loss  of  con- 
sciousness.    Urine  small 
amount  and  black.     Col- 
lapse, death. 


Empty  stomach  by  emetic 
and  tube.  Avoid  fats  and 
oils. 

Alcohol,  magnesium  sul- 
phate, syrup  of  lime,  al- 
bumin. 

Atropin.  Stimulants, 
external  heat,  artificial  res- 
piration. 


CAUSTlt  ALKA- 
LIES 

Caustic  soda 
Caustic  potash 
Concentrated  lye 
Strong  ammonia 

water 
Lime 

Carbonate  of  soda 
Carbonate  of 
potash 


Pain  in  mouth  and 
stomach.  Pain  on  swal- 
lowing. Vomiting  and 
purging  of  mucus  and 
blood.  Skin  cold  and 
clammy.  Feeble  pulse, 
stupor,  coma,  and  death. 


If  signs  of  corrosion,  avoid 
use  of  stomach  tube  and 
emetics.  Use  demulscents 
to  protect  mucosa  after  giv- 
ing chemical  antidote. 

Dilute  vegetable  acids 
freely,  such  as  citric  and 
tartaric,  lemon  and  orange 
juice,  vinegar,  milk,  oil. 

Stimulants,  artificial  heat. 


MINERAL  ACIDS  Pain  along  entire  di- 
Hydrochloric  acid  gestive  tract,  thirst,  dif- 
Sulphuric  acid  ticult  swallowing.  Vom- 

Nitric  acid  ited   material  dark    co- 

Nitro-hydrochloric  lored  and  containing 
acid  shreds   of    membrane. 

Feeble  pulse,  clammy 
skin,  collapse.  Hydro- 
chloric produces  white 
stain  on  tissue,  sulphuric 
acid  a  corroded  black  ap- 
pearance, nitric  and 
nitro-hydrochloric  a  yel- 
low stain. 


Do  not  use  stomach  tube 
or  emetics.  Avoid  water  in 
case  of  sulphuric  unless  it 
can  be  given  in  large  amounts 
as  it  generates  heat  and  in- 
creases injury. 

Other  cases  use  water 
freely  and  demulscents. 

Magnesia,  soap,  albumin, 
lime  water,  whiting,  wall 
plaster.  Avoid  carbonates, 
as  they  liberate  carbon  diox- 
ide and  may  rupture  stomach 
wall. 

Stimulants,  external  heat, 
oil  enemata.  Protect  ex- 
ternal parts  like  ordinary 
burn. 


OXALIC  ACID  Hot,    sour    taste    in 

Oxalic  acid  mouth.     Burning  sensa- 

Potassium  oxalate  tion  in  esophagus  and 
Potassium  binox-      stomach.  Intense  thirst, 
alate  Headache.  Tongue  swol- 

len. Vomiting  of  acid, 
bloody  mucus.  Cold  skin, 
coma,  collapse,  occasion- 
ally convulsions.  Urine 
scanty  and  albuminous. 


Avoid  use  of  stomach  tube. 
Emetics  may  be  used  in  most 
cases.  Safer  to  induce  vo- 
miting by  irritating  fauces 
with  feather.  Castor  oil  and 
magnesium  sulphate  to 
empty  intestinal  tract. 

Lime  in  any  form  such  as 
chalk,  whiting  or  plaster. 
Magnesia  is  also  of  value. 
Caustic  alkalies  of  no  value 
so  far  as  poison  is  concerned. 

Stimulants. 


ALCOHOL 

Ethyl  Alcohol 
Whiskey 
Brandy 
Rum 


GENERAL  NURSING 
III.   NEUROTICS 


Confusion,  giddiness, 
relaxation  of  body,  hal- 
lucinations, stupor,  anes- 
thesia, weak  pulse,  skin 
cool  and  moist,  pupils 
dilated,  breathing  noisy, 
may  be  convulsions. 
Odor  of  alcohol  on  breath. 


Fresh  air.  Empty  stomach 
by  tube  or  emetic. 

Chemical  antidote,  none. 

Artificial  heat.  Support 
by  aromatic  spirits  of  am- 
monia. Galvanic  currenr, 
hot  and  cold  applications, 
oxygen. 


ANTIPYRETICS, 

COAL  TAR 
Acetanilid 
Phenacetin 
Antipyrin 


Sweating,  depression, 
cyanosis,  collapse. 


Put  patient  in  recumbent 
position.  Loo  sen'clothing. 
Evacuate  stomach  with  tube 
or  emetic. 

Chemical  antidote,  none. 

Artificial  heat.  Artificial 
respiration. 


BELLADONNA 
Tr.  Belladonna 
Extract  Bella- 
donna 
Atropin 


Dryness  in  mouth  and 
throat.  Great  thirst, 
dilated  pupils.  Indis- 
tinct vision,  giddiness, 
dry  skin,  nausea,  vomit- 
ing. Stupor.  May  be 
excitement.  Coma, 
death. 


Evacuate  stomach  by  tube 
or  emetic. 
Tannic  acid. 
External  heat,  stimulants. 


CHLORAL 
Chloral 
Chloral  hydrate 


Loss  of  muscular 
power.  Sleep,  coma, 
weak  respiration,  weak 
pulse,  first  slow  then  ra- 
pid and  thready.  Face 
white  and  sweaty.  Tem- 
perature low.  May  be 
delirium. 


Empty  stomach  by  tube 
or  mustard  emetic. 

Liquor  potassae  1-2  to  2 
drams  in  glass  of  water 
hourly  as  required. 

Oxygen  inhalation.  Cold  to 
head.  Inhalation  of  am- 
monia. 


ANESTHETICS 
Chloroform 
Ether 


Stertorous  breathing, 
irregular  and  shallow. 
Dilated  pupils,  conjunc- 
tival  reflex  absent.  Same 
when  taken  by  mouth  as 
when  inhaled. 


Remove  anesthetic  if  being 
inhaled.  Artificial  respira- 
tion. Empty  stomach  by 
tube. 

Chemical  antidote,  none. 

Cold  water  in  face  and  on 
chest.  Atropin  sulphate 
1-100  gr.  hypodermatically. 
Friction  and  external  heat. 


CARBON 

MONOXIDE 


Dizziness,  headache, 
may  be  nausea  and  vom- 
iting. Pupils  dilated. 
Choking,  gasping,  col- 
lapse. 


Remove  to  fresh  air.  Ar- 
tificial respiration. 

Chemical  antidote,  none. 

Oxygen  inhalation,  heat  to 
extremities  and  body.  Heart 
stimulants  like  cold  to  chest. 


COMMON  EMERGENCIES 


53 


COCAIN 

Cocain  hydro- 
chlorate 


Nervous  excitement, 
:-ense  of  oppression,  and 
falness  in  head.  Some- 
times nausea  and  vomit- 
ing. Pulse  slow,  respi- 
ration labored.  Face 
may  be  cyanotic.  Pupils 
dilated,  cold  extremities. 
Convulsions,  coma, 
death. 


Fresh  air,  patient  in  hori- 
zontal position.  Artificial 
respiration.  Empty  stomach 
if  cocain  was  swallowed. 

Chemical  antidote,  none. 

Stimulants  for  heart  and 
respiration.  Cold  compress 
to  chest.  External  heat. 
Oxygen  inhalation.  Cath- 
artic and  enema. 


DIGITALIS 

Tr.  digitalis 
Extract  of  digit- 
alis 

Infusion  of  digit- 
alis 


Vomiting,  purging, 
headache,  eyes  bulging. 
Bl'ie  sclerotic?;  vertigo; 
salivation;  pulse  small, 
slow,  irregular;  face 
pale.  Suppression  of 
urine,  delirium,  convul- 
sions. Coma,  death  sud- 
denly. 


In  horizontal  position. 
Evacuate  stomach  by  tube 
or  emetics.  Wash  stomach 
with  tannic  acid  solution. 

Chemical  antidote,  none. 

Epsom  salts,  stimulants 
like  ammonia. 


HYDROCYANIC  Breath  odor  of  bitter 

ACID  almonds.     Respiration 

Hydrocyanic  acid  difficult,  pulse  imper- 
Potassium  cyanide  ceptible.  Eyes  prom- 
inent. Pupils  dilated. 
Convulsions,  asphyxia, 
cyanosis,  paralysis,  col- 
lapse, coma,  death. 


Artificial  respiration. 
Evacuate  stomach  after 
antidote. 

Ferrous  sulphate.  Hydro- 
gen peroxide. 

Cold  water  over  face. 
Stimulate  with  ammonia. 
Artificial  heat,  electricity. 


IODOFORM  Drowsiness,  slight  de-        Remove  iodoform  dress- 

lodoform  lirium,     high     tempera-  ings  if  in  use. 

ture,  rapid  pulse,  menin-        Chemical  antidote,  none, 
geal  symptoms.  Stimulants. 


NUX  VOMICA 
Tincture  nux 

vomica 
Extract  nux 

vomica 
Strychnin 


Sense  of  suffocation. 
Difficulty  in  breathing. 
Stiffness  about  neck. 
Tetanic  convulsions. 
Opisthotonos,  great 
anxiety.  Jaw  muscles 
affected  late.  Death. 


Empty  stomach  early  be- 
fore convulsion. 

Tannic  acid,  potassium 
permanganate. 

Artificial  respiration. 
Chloroform  for  convulsions. 
Neutral  bath,  bromides, 
chloral. 


NICOTIN 

Nicotin 


Languor,  numb  feel- 
ing in  head,  confused 
mind,  nausea,  cyanosis, 
dilated  pupils,  ^convul- 
sions, coma. 


Evacuate  stomach  by  tube 
or  emetic  like  syrup  of 
ipecac. 

Chemical  antidote,  none. 

Stimulants  like  caffeine 
and  ammonia,  alternate  hot 
and  cold  douche,  oxygen  in- 
halation, electricity. 


GENERAL  NURSING 


OPIUM 
Tr.  opium 
Extract  opium 
Camporated  tinct. 

opium 
Morphin 
Codein 
Heroin 


Mental  excitement, 
headache,  drowsiness 
then  sleep.  Contracted 
pupils,  reflexes  lost. 
Cyanosis,  muscular  re- 
laxation, clammy  skin, 
weak  pulse,  coma, 
death. 


Artificial  respiration, 
evacuate  stomach. 

Potassium  permanganate, 
tannic  acid. 

External  heat.  Keep  pa- 
tient awake  by  external 
stimulation. 


NOTE — This  table  is  compiled  from  Brundage  on  Toxicology. 


PART  II 

SURGICAL    NURSING 

This  course  in  Surgical  Nursing  should  be  preceded  by  lec- 
tures on  the  following  topics:— 
I.  History  of  Bacteriology. 
II.  Classification  of  Bacteria  and  their  Relation  to  Surgery. 

III.  Immunization. 

IV.  Sterilization  and  Disinfection. 

THE   PATIENT 

Preparation  of  the  Patient's  Room 

Furniture.  Iron  surgical  bed,  a  dresser,  washstand,  bed- 
side table,  stand,  two  chairs,  and  a  screen.  Curtains,  if  any, 
should  be  of  light,  washable  material.  Rugs  are  never  allowed. 

If,  in  a  private  home,  use  the  same  directions  in  the  selec- 
tion of  a  room  that  are  observed  in  medical  nursing.  The  fol- 
lowing is  the  ordinary  daily  routine  in  cleaning  a  surgical  room 
and  keeping  it  in  order:— 

1.  Wipe  woodwork  and  furniture  with  a  lightly  oiled  cloth, 
the  object  being  to  prevent  dust  in  the  air. 

2.  Wash    crockery — drinking    glasses,    drinking    pitcher, 
washbowl  and  pitcher,  soap  dish  and  slop  jar. 

3.  Change  bed  linen— generally  one  sheet  daily  is  sufficient. 
Air  blankets.     Turn  mattress  if  patient  can  be  moved  to  a  cot 
or  a  wheel  chair. 

4.  Wash  floor  with  a  disinfectant  or  strong  soapsuds  of 
laundry  soap.     During  the  day  keep  floor  free  from  dust  by  oc- 
casionally wiping'  it  with  a  broom  that  is  covered  with  a  cloth 
or  bag. 

5.  Do  not  forget  to  keep  finger  marks  wiped  off  the  bed. 
Also  do  not  forget  to  keep  electric  light  bulb  washed  and  shin- 
ing, also  the  shade. 


56  SURGICAL  NURSING 

6.  Change  towels  on  stands  and  dresser  as  often  as  needed. 

7.  Remember  that  fresh  flowers  always  bring  good  cheer 
and  sunshine  into  the  sick  room. 

8.  Use  one  of  the  dresser  or  washstand  drawers  for  the 
sterile  bowls  and  dressings. 

a.  Put  clean  towel  in  the  bottom. 

b.  Arrange  dressings  and  bowls  in  an  orderly  manner  and  as 
soon  as  the  dressing  wrappers  are  no  longer  needed  return  them 
to  their  proper  place. 

9.  The  urinal  and  bedpans  should  be  scrubbed  thoroly  and 
disinfected   daily.     Also   after  using  they   should  be  thoroly 
rinsed.     If  these  utensils  are  not  properly  cared  for  they  will 
soon  have  a  characteristic  odor,  and  stains  will  be  in  evidence. 

10.  Bowls  should  be  washed  daily  and  those  that  come  in 
contact  with  a  wound  or  raw  surface,   such  as  a  repaired  perin- 
eum, should  always  be  desinfected  before  using. 

11.  Have  on  hand  a  cloth  for  the  floor,  one  for  woodwork 
and  furniture,  one  for  the  crockery  and  one  for  the  bedpan. 
Those  should  be  washed   and  dried  and  labeled  after  using, 
otherwise  a  relief  nurse  is  apt  to  use  one  of  them  for  a  wrong 
purpose.     These  little  precautions  take  very  little  time  and  re- 
sult in  quite  a  saving  of  linen  and  old  cloth. 

12.  Do  not  neglect  to  clean  drinking  tube  daily  with  a  brush 
especially  made  for  that  purpose. 

13.  A  surgical  nurse  should  systematize  the  daily  routine. 
If  this  is  done  much  time  and  labor  are  saved.     A  patient  ap- 
preciates  a   nurse    who  is  a  good  housekeeper.     Avoid  being 
' 'fussy"  and  '  'puttering"  in  the  performance  of  your  duties. 
Plan  ahead  and  make  every  move  count. 

Preparation  of  the  Patient 

The  routine  of  preparation  varies  in  almost  every  hospital 
in  many  details,  but  the  general  plan  is  practically  the  same. 
The  head  nurse  should  receive  from  the  surgeon  in  charge  the 
details  of  the  preparation  and  see  that  his  orders  are  carried  out. 

MAJOR  OPERATIONS 

1.  General  directions.  Simple  methods  for  the  preparation 
of  the  patient  are  now  being  considered  very  favorably.  The 
following  is  an  example  of  such  a  plan:— 


PREPARATION  OF  THE  PATIENT  57 

Pills,  a  saline  cathartic,  or  two  ounces  of  castor  oil,  also  a 
bath  are  given  the  afternoon  or  evening  preceding  the  opera- 
tion. A  light  supper  is  sometimes  allowed. 

The  next  morning  the  patient  is  shaved  and  at  the  appointed 
hour  walks  to  tht  operating  room,  if  able  to  do  so.  Here  the 
special  preparation  of  the  skin  area  involved  in  the  incision  is 
made  just  before  the  operation.  Perhaps  a  still  better  plan  is 
to  shave  the  patient  the  afternoon  or  evening  preceding  the 
operation,  omitting  enemas  or  other  tedious  procedures  on  the 
morning  of  the  operation. 

If  the  iodine  method  of  preparing  the  field  of  operation  is 
to  be  used,  the  bath  should  be  given  and  the  shaving  done  the 
previous  afternoon.  The  first  coat  of  iodine  may  be  applied  in 
the  evening  after  the  skin  has  thoroly  dried. 

2.  Diet.     The  day  before,   the  patient  may  be  allowed  to 
partake  of  his  ordinary  diet,  omitting  highly  proteid  foods,  pas- 
tries and  coarse  vegetables.    A  light  supper  may  be  allowed  the 
night  before  unless  the  operation  is  of  such  a  nature  that  this 
would  be  inadvisable.     No  food  should  be  given  on  the  day  of 
the  operation  unless  the  work  is  to  be  done  late  in  the  afternoon. 

3.  Head  nurse  sees  that  a  specimen  of  urine  is  saved  and 
examined  one  or  two  days  before  the  operation. 

4.  Hair  shampoos  and  other  tedious  procedures  should  be 
given  two  days  before  the  operation. 

5.  If  the  operation  is  gynecological  and  vaginal  douching  is 
ordered,  it  is  well  to  give  this  the  previous  night.     Unless  other- 
wise ordered,  employ  a  1%  green  soap  solution  at  108°,  followed 
by  douching  with  plain  water  at  the  same  temperature. 

6.  Shaving  field  of  operation.     Get  the  shaving  tray  from 
surgical  supply  room.    It  should  contain  the  following  articles:  — 

a.  Shaving  soap. 

b.  Small  piece  of  gauze  for  applying  soap  before  shaving. 

c.  Razor  (safety  preferred). 

d.  Pair  of  blunt  end  scissors. 

e.  Bowl  of  warm  water. 

Clip  hair  from  the  part.  Make  soap  lather,  .apply,  and 
shave.  The  head  nurse  will  give  directions  as  to  the  extent  of 
of  the  area  to  be  shaved. 

The  skin  should  never  be  scrubbed  to  the  point  of  irritation, 
as  a  raw  surface  furnishes  a  good  medium  for  the  growth  of 


r>8  SURGICAL  NURSING 

bacteria.  Also  in  shaving,  exercise  great  caution  to  avoid  irri- 
tating the  skin.  Strong  disinfectants  act  as  irritants,  and  are 
to  be  used  with  care  and  never  upon  sensitive  surfaces  such  as 
the  eye,  labia,  etc.  When  these  surfaces  are  being  prepared 
for  operation,  special  care  should  be  observed  not  to  overdo  the 
cleansing  process. 

7.  Put  on  clean  gown,  slippers  and  bath  robe;  braid  hair  in 
two  braids;  put  to  bed  between  clean  sheets. 

8.  Give  glass  of  fruit  juice,  gruel,  or  malted  milk. 

9.  On  the  morning  of  the  operation  the  following  things  are 
to  be  observed  just  previous  to  the  operation:— 

a.  Record  temperature,  pulse,  and  respiration. 

b.  Remore  the  false  teeth. 

c.  Have  the  patient  urinate  just  before  entering  the  operating 
room. 

d.  In  laparotomy  catheterize  if  ordered. 

e.  Surgical  jacket  or  gown,  stockings,  leggings,  etc.,  should 
be  put  on  the  patient  before  the  anesthetic  is  begun. 

f.  The  nurse  must  not  fail  to  have  the  patient  ready  before 
the  hour  appointed  for  the  operation. 

i 

Special  preparation  to  part,— 

This  is  generally  done  in  the  operating  room.    If  done  in  the 
patient's  room  the  same  aseptic  precautions  are  observed. 

1.  Place  blanket  and  clean  sheet  over  limbs. 

2.  Place  Kelly  pad  under  patient. 

3.  Place  some  impervious  material  that  has  been  disinfected 
around  edges  of  area  to  be  scrubbed  to  protect  the  blanket  and 
gown  from  getting  wet. 

4.  The  clean  nurse  now  places  sterile  towels  over  the  imper- 
vious material.     Then  she  takes  in  each  hand  a  sterile  sponge. 
The  circulating  nurse  pours  over  these  and  also  the  part  to  be 
scrubbed,  sterile  water  and  tincture  of  green  soap.     The  clean 
nurse  scrubs  thoroly  but  avoids  scrubbing  to  the  point  of  irrita- 
tion, as  this  makes  a  fertile  field  for  the  growth  of  bacteria. 
The  green  soap  is  rinsed  off  the  part  about  3  to  5  times  during 
the  procedure.     The  clean  nurse  next  scrubs  the  area  with  al- 
cohol and  then  ether,  special  attention  being  given  to  the  umbi- 
licus.    If  alcohol  and  ether  are  applied  when  the  patient  is  con- 
scious, the  process  is  apt  to  be  very  painful.    After  this  is  done 


PREPARATION  OF  THE  PATIENT  59 

a  sterile  towel  is  placed  by  the  clean  nurse  over  the  disinfected 
area  and  then  the  Kelly  pad  and  rubber  and  wet  towels  are  re- 
moved. 

5.  A  sterile  sheet,  folded  so  as  to  make  four  thicknesses,  is 
now  placed  over  the  limbs,    folding  several  inches  over  the 
blanket.    A  sterile  half  sheet  is  then  folded  and  placed  over  the 
arms,  tucking  in  well  over  the  gown. 

6.  The  sterile  laparotomy  sheet  is  then  placed  over  this. 

7.  Place  sterile  anaesthetic  shield  over  frame  provided  for 
that  purpose. 

Iodine  preparation  to  part. — Formula:— 

Iodine  30  gms.  • 

Potassium  iodid  40  gms. 
Aq.  Dest.  500  c.c. 

Dilute  with  an  equal  volume  of  grain  alcohol.  For  the  sat- 
isfactory action  of  the  iodine,  it  is  essential  that  the  skin  be 
dry.  If  possible,  shave  the  night  before  the  operation.  If  shav- 
ing is  done  just  before  the  operation,  or  the  day  of,  dry  skin 
thoroly  with  towel  and  apply  ether;  then  dry  again.  In  regular 
cases,  the  iodine  preparation  is  first  done  in  the  ward,  the  io- 
dized area  is  then  covered  with  a  sterile  pad  or  towel.  Before 
commencing  the  operation  a  second  application  of  the  iodine 
solution  is  made,  the  skin  then  being  in  a  thoroly  dry  condition. 
If  possible,  it  is  well  to  make  the  first  application  of  iodine  the 
the  night  before  the  operation.  The  second  application  is  made 
just  before  the  patient  enters  the  operating  room  or  on  the  oper- 
ating table.  Some  surgeons  prefer  to  use  5%  tincture  of  iodine. 

Position  of  the  patient  on  the  table. 

I.  Dorsal.  The  patient  is  placed  upon  the  back  with  pads 
under  the  back  and  knees.  Thus  the  strain  that  the  lumbar 
spine  and  sacro-iliac  joints  are  generally  subject  to,  is  avoided. 
The  unnatural  position  of  the  body  on  an  operating  table  often 
causes  post-operative  back-aches  and  a  subsequent  weakening 
of  the  sacro-iliac  joints. 

77.  Trendelenburg  position.  Place  the  patient  in  the  dorsal 
position  with  the  shoulders  resting  against  shoulder  supports. 
Then  lower  the  head  of  the  table  as  much  as  required.  The 
arms  should  be  fastened  loosely  across  the  chest. 


60  SURGICAL  NURSING 

III.  The  lithotomy  position.      Place  the  patient  in  the  dor- 
sal position.     Flex  the  thighs  on  the  abdomen  and  the  legs  on 
the  thigh  with  the  knees  separated.     The  buttocks  should  pro- 
ject well  over  the  edge  of  the  table. 

IV.  The  exaggerated  lithotomy  position.      This  is  similar  to 
the  above,  except  that  the  pelvis  is  elevated.    This  may  be  done 
by  placing  a  large  flat  sand-bag  beneath  the  buttocks  or  by 
combining  with  the  Trendelenburg. 

V.  The  kidney  position.     P:ace  in  either  the  right  or  the 
left  Sim's  position  as  is  needed.     Then  raise  the  *  'kidney  lift" 
of  the  table  until  the  patient  is  in  the  proper  position.     If  a 
table  has  no  "kidney  lift,"  an  oblong  sand-pillow  may  be  placed 
between  the  table  and  the  patient  in  the  proper  place. 

THE  OPERATING  ROOM 

The  operating  room  should  be  on  the  top  floor  and  have  a 
high  ceiling.  The  sky-light  should  be  double,  air  tight,  and  of 
ribbed  glass,  and  shaded  so  that  the  sunlight  will  not  fall  di- 
rectly upon  the  operating  table.  A  north  exposure  is  considered 
the  best. 

The  floor,  walls,  and  ceiling  should  be  tiled,  or  the  floor  of 
cement  and  the  wall  and  ceiling  of  smooth,  hard  wall  plaster. 
The  corners  should  be  round  and  the  heat  should  be  either  hot 
water  or  steam. 

General  rules.  There  should  be  no  confusion  in  an  operat- 
ing room.  Avoid  unnecessary  talking.  Each  member  of  the 
staff  should  have  a  thoro  knowledge  of  his  own  duties  and  also 
of  the  duties  of  others.  Each  movement  should  be  executed 
quickly  and  noislessly  and  without  coming  in  contact  with 
others. 

Preparation  of  the  Operating  Room 

1.  Every  inch  of  space  in  the  room  is  first  washed  thoroly 
with  soap  and  water. 

2.  All  furniture  is  washed  with  a  reliable  disinfectant,  e.  g. 

HgCl2  1/1000. 
Carbolic  2%. 
Lysol  1%. 
Formaldehyde  1%. 


TECHNIQUE  OF  TABLES  61. 

In  addition  to  this  the  glass  of  the  tables  may  be  washed 
with  95%  alcohol,  also  the  electric  light  bulbs.  It  is  preferable 
to  have  two  operating  rooms — one  for  aseptic  and  one  for  septic 
cases.  However,  we  do  not  always  find  this  ideal  arrangement. 
Consequently,  after  each  septic  case  the  room  should  be  sealed 
up  and  thoroly  fumigated.  Full  directions  for  this  are  given 
elsewhere. 

Technique  of  Tables 

1.  Anesthetic  table  (To  the  right  of  the  anesthetist)  :  — 

a.  Place  towel  over  top. 

b.  Chloroform  bottle. 

c.  Ether  mask. 

d.  Two  towels. 

e.  Mouth  sponges. 

f .  Pus  tray  containing  mouth  gag,  tongue  forceps,  and  artery 
forceps. 

g.  Bottle  of  vinegar  (some  anesthetists  give  inhalations  of 
this  at  the  close  of  the  anesthetic  to  prevent  nausea) . 

h.  Tube  of  vaseline. 

i.  Such  other  articles  as  the  anesthetist  may  require. 

2.  Table  of  clean  nurse.     The  following  classes  of  articles 
should  be  arranged  on  the  table  according  to  some  definite  plan. 
In  one  place  put  needles  and  sutures,  near  to  this  such  special 
instruments  as  scissors,  needle  holders,  cervical,  perineal,  and 
aneurysm  needles. 

Reserve  a  place  for  the  instrument  to  be  used  in  the  parti- 
cular operation  to  be  done.  These  should  be  placed  as  needed 
In  the  movable  instrument  tray,  which  is  attached  to  a  foot, 
on  another  place  on  the  table  put  the  sponges  and  such  sterile 
dressings  as  may  be  needed.  Have  in  a  convenient  location  on 
the  table  sterile  safety  pins,  small  sterile  beakers  or  bottles 
containing  such  liquids  as  tincture  of  iodine,  tincture  of  benzoin, 
carbolic  acid,  alcohol,  and  sterile  vaseline.  Also  have  a  package 
of  sterile  cotton  pledgets  and  applicators.  On  the  shelf  under- 
neath are  kept  sterile  sheets,  towels,  napkins,  and  a  reserve 
supply  of  sponges  and  dressings,  also  sterile  dishes  and  rubber 
gloves. 

3.  An  extra  table  in  the  corner  contains  supply  bottles  of 
alcohol,  carbolic,  etc.,  a  supply  of  packing  of  various  sizes  in 


62  SURGICAL  NURSING 

glass  tubes,  wide-mouthed  bottles  or  other  convenient  recept- 
acles, tray  containing  articles  for  final  preparation  of  the  field 
of  operation.  These  articles  vary  according  to  the  technique 
used.  The  following  is  a  suggestive  list.  The  tray  should  be 
set  up  according  to  the  order  of  the  surgeon. 

a.  Large  sponges. 

b.  Tincture  of  green  soap  or  green  soap  solution. 

c.  Sterile  water. 

d.  Alcohol. 

e.  Ether. 

f.  Tincture  of  iodine. 

4.  An  adjustable  standard  for  holding  the  irrigating  appara- 
tus is  needed  in  every  operating  room.    The  irrigating  cans  and 
tubing  must  be  sterile  before  using. 

5.  A  special  stand  holding  one  or  two  bowls  of  sterile  hand 
solutions  are  placed  near  the  surgeon.     These  are  used  by  him 
for  washing  his  hands  as  may  be  necessary  during  the  operation. 

Duties  of  Staff 

After  the  operating  room  is  thoroly  cleaned  according  to 
the  outline  given  elsewere,  one  nurse  scrubs  and  prepares  her- 
self according  to  one  of  the  formulae  given  under  "hand  disin- 
fection. " 

Another  nurse  who  does  not  have  to  be  clean  and  who  is 
commonly  called  the  "circulating  nurse,"  places  on  the  clean 
nurse  a  cap.  She  also  unpins  and  turns  back  the  wrapper  of  a 
surgical  gown  without  touching  the  gown  and  nurse  No.  1  takes 
it  out  and  puts  it  on,  No.  2  tying  the  tapes  in  the  back  and  pin- 
ning the  belt. 

No.  1  does  not  touch  anything  that  is  not  sterile  and  No.  2 
is  careful  not  to  touch  anything  that  is  sterile.  If  this  rule  is 
not  adhered  to,  the  whole  operating  room  technique  is  rendered 
imperfect,  and  as  a  result  a  life  may  be  sacrificed.  It  is  very 
true  that  a  chain  is  no  stronger  than  its  weakest  link,  so  a  sur- 
gical technique  is  just  as  strong  as  its  weakest  point. 

No.  1  and  No.  2  are  now  ready  for  work  in  the  operating 
room.  No.  2  unpins  and  turns  back  the  outside  wrapper  of  a 
bundle  and  No.  1  unpins  the  second  wrapper  and  removes  it 
when  needed. 


DUTIES  OF  STAFF  63 

First  a  sterile  sheet  is  placed  over  the  table  used  by  clean 
nurse.  Then  dressings,  supplies  and  dishes  are  arranged  so 
that  they  may  be  readily  secured. 

While  she  is  doing  this  No.  2  sets  the  anesthetic  table  and 
the  general  table. 

THE  DUTIES  OF  THE  '  'CLEAN  NURSE"   (NO.  1)  AT  OPERATION 

1.  As  a  general  rule  No.  1  is  the  nurse  in  charge  of  the 
operating  room. 

2.  Places  laparotomy  sheet  over  the  patient,   after  placing 
sterile  towels  or  sheets  over  the  edges  of  the  sheet  and  blanket 
that  are  already  on  the  patient. 

3.  Helps  to  hand  instruments. 

4.  Washes  soiled  instruments. 

5.  Keeps  plenty  of  sterile  sponges  on  hand  for  the  surgeon. 

6.  Counts  laparotomy  sponges  and  napkins. 

7.  Prepares  sutures  and  threads  all  needles. 

8.  Anticipates  the  needs  of  the  surgeon  and  his  assistant. 

9.  Watches  the  whole  staff  to  see  that  the  surgical  technique 
is  not  broken.     If  it  is,  she  sees  that  steps  are  at  once  taken  to 
mend  the  broken  link. 

THE  DUTIES  OF  THE  ' 'CIRCULATING  NURSE"   (NO.  2) 

1.  Changes  solutions  as  needed. 

2.  Runs  the  irrigator. 

3.  Sees  that  all  supplies  are  kept  up. 

4.  Under  No.  1,   number  2  is  responsible  that  everything 
in  operating  room  is  kept  in  order  during  an  operation. 

5.  Anticipates  the  needs  of  all  the  staff. 

6.  Should  stand  on  the  alert,   ready  to  assist  in  any  way 
possible. 

Hand  Disinfection 

1.  Trim  the  nails  as  short  as  possible  and  clean  them. 

2.  With  green  soap  or  some  special  brand  of  soap,  selected 
by  the  surgeon,  the  hands  and  arms  to  above  the  elbows  are 
to  be  thoroly  scrubbed.    This  requires  about  ten  minutes,  during 
which  time  the  parts  should  be  frequently  rinsed  (five  or  six 
times). 

3.  Chemical  disinfection  follows  the  last  rinsing.     For  this 
various  methods  are  in  vogue. 


64  SURGICAL  NURSING 

I.  a.  Hot  saturated  solution  of  potassium  permanganate,  until 
the  parts  are  well  stained. 

b.  Saturated  oxalic  acid  solution  to  decolorization. 

c.  Warm  sterile  water. 

//.  a.  Acid  solution  of  bichloride  of  mercury  for  five  minutes, 
b.  Sterile  water. 

///.  a.  Cover  parts  with  paste  of  chloride  of  lime  and  water. 

b.  Apply  sodium  carbonate. 

c.  Remove  very  carefully  all  this  mixture  with  bichloride  of 
mercury  1/1000,  using  a  piece  of  sterile  gauze. 

d.  Immerse  in  alcohol. 

e.  Rinse  in  solution  of  1%  carbolic  acid. 

To  facilitate  the  removal  of  lime  and  soda  mixture,  the 
hands  and  arms  may  be  immersed  in  a  2%  solution  of  sodium 
carbonate. 

IV.  Alcohol  (70%  or  75%)  for  two  minutes. 

There  are  various  modifications  of  these  methods.  Some 
prefer  to  finish  any  method  by  rinsing  the  hands  in  bichloride. 
Others  after  simple  scrubbing  with  green  soap  or  mechanic's 
soap,  rinse  the  hands  with  sterile  water  and  then  immerse  in 
Harrington's  solution  30  seconds  to  one  minute,  and  finally 
rinse  in  alcohol. 

Formula  for  Harrington's  solution,— 
Grain  alcohol  640  c.c. 

Water  300  c.c. 

Hydrochloric  acid  C.  P.       60  c.c. 
Bichloride  of  mercury  0.8  gm. 

Some  surgeons  find  it  impossible  to  use  strong  chemicals  on 
the  hands  because  of  the  resulting  irritation  and  dermatitis, 
and  hence  use  very  simple  methods,  depending  largely  upon 
mechanical  cleanliness. 

Sterilizing  Room 

1.  General  preparation  the  same  as  for  the  operating  room. 

2.  A  tripod  or  side  table  contains  three  or  four  bowls  for 
hand  solutions  also  a  bowl  of  nail  brushes  and  files  that  are  im- 
mersed in  a  solution  of  formaldehyde  2%  or  green  soap  2  1/2%, 
and  a  package  of  sterile,  surgeon's  towels. 


METHODS  OF  STERILIZATION  65 

3.  The  stationary  bowls  for  the  scrubbing  of  the  hands  are 
scrubbed  with  bon  ami,  or  some  good  cleaning  preparation,  and 
the  faucets  and  drain  pipes  are  polished.  This  room  contains  a 
general  work  table. 

Instruments  and  Supply  Room 

The  general  preparation  of  this  room  is  the  same  as  the 
sterilizing  room.  It  contains  the  sterilizer,  tanks  containing 
hot  and  cold  sterile  water,  a  tank  for  boiling  bowls,  etc.,  an 
instrument  boiler,  also  the  instrument  case,  the  cupboard  for 
surgical  dressings,  a  cupboard  for  general  supplies,  and  a  work 
table. 

Methods  of  Sterilization 

RUBBER  GLOVES 

No.  1.  Dry  method.  Soak  new  gloves  in  soap  and  water 
for  twenty-four  hours;-  boil  for  five  minutes.  This  is  to  render 
them  pliable:  rinse,  dry  on  both  sides,  powder  on  inside,  being 
careful  to  shake  powder  out  of  finger  tips.  Mate  the  gloves. 

Inside  the  wrist  of  each  glove  place  a  piece  of  gauze,  and  a 
piece  lengthwise  between  each  pair  of  gloves  to  prevent  them 
sticking.  Put  each  pair  up  separately  in  muslin  or  towel,  mark 
with  owner's  name,  and  sterilize  for  twenty  minutes  under  ten 
pounds  pressure. 

After  each  operation,  cleanse  gloves  on  inside  and  outside 
by  scrubbing  with  soap  and  water,  rinse,  test,  and  mend.  Boil 
five  minutes  in  1/4%  soda  sol.,  rinse  in  ammonia  water,  dry  on 
inside  and  outside,  powder  and  proceed  as  before.  If  seamless 
gloves  are  used,  it  is  best  to  powder  them  on  both  sides,  as  they 
stick  together. 

To  be  used  after  thoroly  disinfecting  hands;  dry  with  sterile 
towel,  powder  hands  (not  gloves)  with  sterile  talcum  and  draw 
on  gloves. 

ATo.  2.  Wash  thoroly  in  green  soap  and  water;  rinse.  Boil 
5  minutes  in  saline  or  soda  solution.  Immerse  in  5%  green  soap 
solution  or  HgCl2  1—3000.  Fill  gloves  with  solution  so  that  they 
may  be  easily  and  quickly  put  on. 

BRUSHES 

Hand  brushes  and  nail  cleaners  are  boiled  15  to  20  minutes 
and  then  placed  in  a  solution  of  2%  formaldehyde  or  5%  green 
soap. 
5 


66  SURGICAL  NURSING 

The  Kelly  pad  is  washed  thoroly  with  soap  and  water  and 
disinfected  in  5%  carbolic  or  bichloride  1-1000.  The  objection 
to  the  latter  is  that  it  blackens  rubber. 

Drainage  tubes  are  washed  thoroly  in  green  soap  and  water 
and  rinsed.  Boil  one-half  hour  just  before  using. 

Gutta  percha  tissue  is  immersed  in  HgCU  1-1000,  one-half 
hour  before  using. 

Rubber  sheets  are  disinfected  in  5%  carbolic  acid  solution. 

SUTURES 

Catgut  is  made  from  the  intestines  of  sheep.  It  is  softened 
and  absorbed  by  the  fluids  of  the  body  and  hence  it  is  used 
within  the  abdominal  cavity  or  deeper  layers  of  tissues. 

In  many  hospitals  this  is  purchased  from  firms  who  prepare 
it  for  use  and  put  it  up  in  glass  tubes  containing  alcohol 

There  are  various  formulae  for  preparing  it.  These  may 
be  found  in  any  text  on  surgical  nursing. 

Kangaroo  tendon  is  prepared  from  the  split  sinews  of  the 
tail  of  that  animal.  Its  advantage  over  catgut  consists  in  its 
greater  strength. 

Silkworm  gut  is  generally  prepared  by  boiling  one-half  hour 
before  an  operation.  It  is  seldom  employed  as  a  buried  suture, 
but  is  much  used  in  closing  wounds  with  interrupted  sutures. 

Silk  and  linen  are  prepared  for  use  in  the  same  manner. 

DRESSINGS 

Small  sponges— 6x9  in.  Fold  each  edge  of  the  longest  di- 
mension to  the  center.  Then  bring  the  ends  together  at  the 
center.  Fold  again  so  that  a  perfect  square  is  formed. 

Large  sponges— 9x18  in.  They  are  made  the  same  as  the 
small  sponges. 

Large  laparotomy  napkins.  Gauze,  36x36  in.  When  finished 
the  dimensions  are  12x16  in. 

Rollers.     Gauze,  36x36  in. ;  finished,  34x4  in. 

Laparotomy  napkins.     Gauze,  36x18  in. ;  finished,  16x8  in. 

Abdominal  dressing.  Gauze,  30x36  in. ;  folded,  16x8  in. 
Combination.  Gauze,  30x20;  cotton,  16x12;  finished,  16x12  in. 
Fluff,  6  pieces,  18x18  in. 

Perineal  dressing.  Cotton,  4x6  in. ;  Gauze,  12x9  in.  Fin- 
ished, 4x6  in. 


METHODS  OF  STERILIZATION  67 

Perineal  pads.  Gauze,  12x18  in. ;  Cotton,  5x9  in.  Finished, 
5x9  in. 

The  towels,  napkins,  rollers,  abdominal  dressings,  sheets, 
perineal  dressings  and  pads,  are  done  up  in  packages  containing 
6,  12  and  24  each.  The  large  sponges  are  done  up  in  packages 
of  12  and  24  each. 

Surgical  gowns,  sheets,  dressings,  towels,  napkins,  lap- 
arotomy  sheets,  are  all  wra  ped  in  two  heavy  muslin  wrappers- 
and  sterilized  for  one  hour  under  fifteen  pounds  pressure. 
This  kills  the  spores  as  well  as  the  bacteria,  so  that  fractional 
sterilization  is  unnecessary. 

PACKING  ' 

One-fourth  inch.  Cut  strip  of  gauze  1  inch  wide.  Pull  a 
thread  to  cut  by,  to  make  it  perfectly  even.  Fold  each  edge  to  the 
center  lengthwise,  then  bring  the  outer  edges  together.  This 
makes  a  strip  1/2  of  an  inch  in  width  and  four  thicknesses  of 
gauze.  Pack  in  a  glass  test  tube  or  a  small  wide-mouthed 
bottle,  and  place  a  stopper  of  absorbent  cotton.  Label  and 
sterilize  in  the  usual  manner. 

In  making  any  width  of  packing,  the  strips  are  cut  five 
yards  long.  The  width  of  the  gauze  should  be  four  times  the 
width  of  the  packing  when  finished. 

IODOFORM  GAUZE 

Formula,— 

1.  Alcohol        3  parts. 

2.  Glycerine    2  parts. 

3.  lodoform  sufficient  to  make  the  consistency  of  cream. 
One  nurse  scrubs  up  as  for  an  operation.     We  will  call  her 

No.  1  and  her  assistant  No.  2. 

No.  1  takes  a  sterile  cotton  pledget  and  No.  2  pours  on  it  a 
little  alcohol.  No.  1  then  wipes  the  edges  of  the  glycerine 
bottle,  being  careful  that  her  fingers  touch  nothing  but  the 
pledget. 

No.  2  measures  out  the  glycerine  and  alcohol  into  a  sterile 
graduate  and  pours  into  a  sterile  bowl.  She  then  pours  in  the 
iodoform  powder  while  No.  1  stirs  with  a  steril^  spoon  until  the 
solution  is  of  the  consistency  of  cream.  No.  2  then  removes  the 
plug  from  a  tube  of  sterile  packing  while  No.  1  with  sterile  for- 
ceps removes  the  same  and  puts  in  the  solution  already  made. 


68  SURGICAL  NURSING 

Here  she  saturates  the  gauze  with  the  solution,  being  careful 
that  the  iodoform  is  evenly  distributed  thru  the  gauze.  Then 
the  gauze  is  wrung  dry  and  packed  into  a  sterile  tube  as  before, 
a  sterile  plug  being  placed. 

INSTRUMENTS 

Surgeons  differ  in  regard  to  sterilization  of  instruments. 
The  following  method  is  highly  approved  by  many  surgeons:— 

Have  a  1%  solution  of  sodium  carbonate  boiling  in  the  in- 
strument boiler.  Wrap  the  instruments  in  a  towel  and  drop  in. 
Boil  for  one-half  hour.  The  sodium  carbonate  helps  to  prevent 
rusting. 

All  edged  instruments  to  be  boiled  should  be  wrapped  in 
cotton.  Knives  and  scissors  should  be  immersed  in  carbolic 
95%  for  five  minutes  and  then  rinsed  in  sterile  water  and 
dipped  in  boiling  water.  If  left  for  a  longer  time  in  the  carbolic 
or  if  boiled,  they  lose  their  temper  and  are  apt  to  rust. 

When  the  instruments  have  boiled  sufficiently,  the  clean 
nurse  dries  them  on  sterile  towels  and  places  them  on  trays 
ready  for  use. 

If  perchance  an  instrument  should  fall  to  the  floor,  the 
"circulating"  nurse  picks  it  up,  and  if  it  happens  to  be  one 
that  is  much  needed,  it  is  washed  and  rinsed  and  then  immersed 
in  carbolic  for  five  minutes.  It  is  then  rinsed  in  sterile  water 
and  is  ready  for  use. 

After  the  operation  the  instruments  should  be  taken  apart, 
washed  in  cold  water  to  remove  blood  and  pus  and  any  particles 
that  may  be  adherent.  Scrub  thoroly  with  green  soap,  being 
careful  not  to  neglect  any  crevices  or  niches.  Boil  for  fifteen 
minutes  in  1%  sol.  of  sodium  carbonate.  If  the  case  has  been 
a  ' 'clean"  one,  boiling  is  omitted,  as  this  is  done  before  the 
the  next  operation  anyway.  Dry  thoroly,  wrap  all  knife  blades 
and  sharp-edged  instruments  in  absorbent  cotton,  and  then  put 
away. 

DISHES  AND  UTENSILS 

Wash  with  soap  and  water  and  dry.  Boil  20  minutes  or 
wrap  in  pillow  cases  or  towels  and  sterilize  in  the  usual  manner 
in  the  autoclave. 

The  "circulating  nurse"  should  always  handle  dishes  by 
taking  hold  from  the  outside,  never  inside  or  over  the  edge. 


METHODS  OF  STERILIZATION  69 

SOLUTIONS 

In  the  part  on  '  'Solutions"  the  system  of  calculating  quan- 
tity and  proportion  is  fully  taken  up.  In  this  connection  only 
the  technique  of  sterilizing  solutions  will  be  considered. 

NORMAL  SALT 

It  is  better  to  make  this  solution  fresh  whenever  it  is  needed. 
Keep  sterile  saturated  solution  on  hand  or  the  sterile  tablets. 

Take  a  sterile  enamel  bowl  and  measure  out  with  a  sterile 
measure  the  required  amount  of  sterile  water  needed.  If  the 
tablets  are  to  be  used,  with  sterile  forceps  place  in  the  water 
the  number  of  tablets  needed  to  make  a  normal  salt  solution. 
If  the  saturated  solution  is  used,  measure  out  of  flask  or  bottle 
the  amount  needed  into  a  sterile  graduate  and  pour  into  water. 
Heat  this  to  the  proper  temperature  and  pour  into  whatever 
receptacle  has  been  prepared. 

In  many  hospitals  the  sterile  normal  salt  is  kept  on  hand 
ready  for  immediate  use  Into  a  clean  flask  pour  a  normal  salt 
solution  from  which  all  particles  and  sediment  have  been  re- 
moved by  steaming,  filtering,  or  letting  stand  until  all  sediment 
has  settled  to  the  bottom  and  then  decant  the  upper  portion. 

Place  stoppers  of  sterile  cotton  plugs  and  sterilize  by  boil- 
ing one  hour  on  three  successive  days. 

STERILE  SATURATED  SOLUTION  OF  SALT 

Salt  saturates  1 — 2  1/2.  Take  an  enamel  pail.  Place  in  It  1 
part  of  salt  and  21/2  times  as  much  water.  Skim  often  when 
boiling.  Boil  1  hour,  after  which  let  it  stand  until  cool.  Take 
a  sterile  bottle  and  place  in  it  a  sterile  funnel.  With  a  sterile 
dipper,  put  solution  in  the  bottle,  pouring  from  the  dipper  thru 
the  funnel.  Place  a  sterile  plug. 

STERILE  GLYCERINE 

Place  an  uncovered  glass  jar  filled  with  glycerine  in  the 
sterilizer.  Beside  it  put  the  lid.  Sterilize  for  one  hour  under 
fifteen  pounds  pressure.  If  no  sterilizer  is  at  hand,  use  a  double 
boiler  and  keep  the  water  boiling  under  the  glycerine  two  hours. 
Sterile  vaseline  and  other  oils  are  prepared  in  the  same  manner. 


70  SURGICAL  NURSING 

TINCTURE  OF  GREEN  SOAP 

Green  soap  3  parts. 
Alcohol  (95%)  2  parts. 
Ether  1  part. 

Mix  ingredients  in  a  pitcher  and  stir  briskly  for  a  few  min- 
utes every  hour  until  a  solution  is  formed. 

Suggestive  Operative  Record 


Name__  .    Address 


Friend  or  relative 
Diagnosis 

Operation  proposed. _ 

Preparations  required — Usual Special 

Condition  of  patient  on  morning  of  operation 

Urine — amount Sp.  Gr Urea gm Alb Sugar Casts 

Blood— Hem.  _.       _  R.  C W.  C Heart T P R 

Anesthetic  begun  _  _  _     _  _  _  Anesthetic  employed Anesthetist 

Amount  used -.Hypodermics  given 

Operation  begun__  __  Completed Incision 

,  Sutures 

Drainage Packing Dressings 

Amount  blood  lost— great considerable little none 

Condition  of  patient  at  end  of  operation _ 

Description  of  operation 


OPERATION  IN  PRIVATE  HOME  71 

Surgeon !___,. 

Assistant ___L 

Packing  removed Drainage  removed 

Sutures  removed 1 

Daily  record  .. 


Preparation  for  an  Operation  in  a  Private  Home 

LOCATION  OF  ROOM 

1.  Select  a  room  that  has  an  abundance  of  clear  light. 

2.  Avoid  if  possible  a  room  where  sun  will  shine  directly 
upon  the  operating  table  during  the  operation. 

Discuss  the  following  with  the  surgeon  beforehand:— 

a.  The  matter  of  the  source  of  light. 

b.  The  anesthetic. 

c.  Means  of  ventilation.  t 

4.  Choose  a  room  as  near  the  bedroom  of  the  patient  as 
possible. 

5.  If  necessary  to  use  patient's  bedroom  for  an  operating 
room,  prepare  the  bed  and  push  it  into  the  corner  out  of  the  - way. 

PREPARATION  OF  ROOM 

1.  If  there  is  sufficient  time  remove  all  hangings,  draperies, 
carpets,  rugs,  and  all  unnecessary  furniture. 

2.  Thoroly  scrub  floor  and  walls.  > 

3.  If  there  are  just  a  few  hours  before  the  room  is  to  be 
made  use  of,   it  is  better  not  to  disturb  anything — not  even  to 
sweep  the  floor.     Cover  all  pictures,  hangings  and  large  pieces 
of   furniture  with  sheets   wrung  out  of  a  solution  of  HgCl2 
1-1000.     The  floor  should  be  similarly  covered.     Under  sheets 
about  operating  table  place  newspapers  or  heavy  papers  to  pre- 


72  SURGICAL  NURSING 

vent  the  floor  underneath  from  getting  stained  with  blood,  etc. 
Pin  or  tack  sheets  to  side  walls  to  a  height  of  five  or  six  feet. 

FURNITURE 

1.  Operating  table.     Generally   kitchen   table   or  ironing 
board  is  made  use  of.     Two  small  tables  can  be  placed  together. 
Pull  apart  an  extension  table  and  lay  two  boards  on  the  leaves 
lengthwise  across  the  gap.     Pad  with  blanket  and  cover  with 
rubber  sheet  and  freshly  laundered  sheet. 

2.  Four  small  tables  for  instruments,  anesthetics,   dress- 
ings, and  solutions. 

3.  Place  for  surgeons  to  scrub  up.     This  is  preferably  done 
in  a  room  adjoining,  but  of  course  this  is  not  always  possible. 

Wipe  all  furniture  with  an  oiled  cloth.  Scrub  when  old  and 
dirty.  Cover  tables  with  sterile  towels. 

SUPPLIES  NEEDED 

1.  Dishes:— 

a.  Three  large  basins. 

b.  Two  large  pitchers. 

c.  Three  small  basins. 

d.  One  small  pitcher. 

e.  Four  small  glasses. 

Scrub  thoroly  with  soapsuds.  Rinse  and  boil  one-half  hour 
before  operation.  If  this  is  not  possible,  let  them  stand  in  1-1000 
HgCl2  at  least  one  hour  before  operation. 

2.  Fountain  syringe. 

3.  Rubber  sheeting  for  table. 

4.  Foot  tub  for  soiled  sponges. 

5.  Large  pail  for  dirty  solutions,  etc. 

6.  Plenty  of  hot  and  cold  sterile  water. 

7.  Safety  pins. 

8.  Absorbent  cotton. 

9.  Alcohol. 

10.  Sterilized  dressings,  sheets,  gowns,  and  plenty  of  towels. 

11.  Four  wooden  nail  brushes. 

12.  Antiseptic  solutions  as  ordered. 

13.  A  Kelly  pad  can  be  improvised  by  tightly  rolling  a  blanket 
and  covering  with  a  rubber  sheet,  two  ends  of  which  are  to  be 
pinned  together  and  thus  the  solution  will  flow  into  the  recept- 
acle below. 


ANESTHETICS  AND  ANESTHESIA  73 

The  surgeon  brings  his  own  instruments  and  the  anesthetic, 
also  rubber  gloves. 

AN  EMERGENCY  STEAM  STERILIZER 

Use  an  ordinary  wash  boiler.  Place  in  bottom  a  crate  made 
of  three  light  boards  placed  edgewise  and  a  few  slats  nailed 
across.  The  crate  should  be  six  inches  above  the  bottom  of  the 
boiler.  Pack  parcels  in  loosely  so  that  the  steam  will  circulate 
freely  in  and  around  them.  Have  water  boiling  in  bottom  of 
boiler  and  sterilize  for  11/2  hours.  Take  parcels  out  and  dry 
either  in  the  sun  or  in  an  oven.  If  placed  in  the  latter  they 
will  need  to  be  watched  very  carefully  as  it  is  easy  to  scorch  or 
burn  them. 

Anesthetics  and  Anesthesia 

As  a  rule  nurses  have  very  little  to  do  with  the  giving  of 
anesthetics  more  than  assistance,  altho  in  some  hospitals  nurses 
having  had  special  preparation  and  experience  are  given  charge 
of  administering  anesthetics.  It  is,  however,  necessary  that 
the  nurse  understand  the  general  effects  of  anesthetics  and 
something  of  their  mode  of  administration  and  under  what 
circumstances  they  are  used. 

1.  General  anesthetics.     Those  most  frequently  employed 
are  ether  and  chloroform.     They  produce  unconsciousness  and 
general  insensibility  to  common  sensations  including  pain.    They 
are  used  in  nearly  all  major  and  many  minor  operations. 

2.  Local  anesthetics.      These  are  such  substances  as  cocain 
and  ethyl  chloride,  which  when  applied  locally  produce  anes- 
thesia in  the  part  to  which  they  are  applied.     They  are  used  in 
minor  surgery,  operations  upon  the  nose  and  throat,  lancing  of 
boils,  etc. 

3.  Spinal  anesthesia  is  carried  out  by  means  of  such  sub- 
stances as  stovain,  tropacocain,  etc.     It  produces  anesthesia  in 
all  parts  below  the  region  of  injection. 

ETHER 

Ether  by  the  modern  drop  method  is  considered  the  safest 
of  all  general  anesthetics.  In  many  hospitals  it  is  being  used 
almost  exclusively.  When  begun  slowly  and  given  in  an  even, 
uniform  manner,  there  is  less  difficulty  in  securing  prompt 
anesthesia  and  much  less  disturbance  on  the  part  of  the  patient 


74  SURGICAL  NURSING 

than  when  given  by  the  old  closed  inhaler  system.  As  ether  is 
very  inflammable,  it  is  dangerous  to  have  an  open  flame  any- 
where near  while  it  is  being  administered.  It  is  a  stimulant  to 
the  heart  and  respiration,  so  that  the  force  of  the  pulse  wave  is 
somewhat  heightened.  As  with  other  anesthetics  the  patient 
passes  thru  three  stages,  (a)  the  exciting  stage,  (b)  light  an- 
esthesia, (c)  profound  (or  surgical)  anesthesia.  The  length  of 
the  exciting  stage  will  depend  somewhat  upon  the  condition 
and  cemperament  of  the  patient.  It  is  apt  to  be  rather  pro- 
longed and  troublesome  in  those  addicted  to  alcohol.  For  major 
operat;ons  the  third  stage  must  be  attained.  For  this  reason 
this  sta^e  is  often  spoken  of  as  that  of  surgical  anesthesia. 

Points  relating  to  the  elimination  of  ether  are  considered 
under  '  'After  Treatment. " 

CHLOROFORM 

Chloroform  produces  more  prompt  anesthesia,  must  be 
given  with  more  air,  and  is  more  depressing  to  the  heart  than 
ether.  While  it  is  still  used  much  as  a  general  anesthetic  for 
adults,  especially  for  brief  operations,  in  some  hospitals  it  is 
being  used  only  in  infants  for  such  operations  as  hare-lip,  cleft 
palate,  etc.  Chloroform  is  also  much  more  toxic  than  ether, 
and  occasionally  results  in  degeneration  of  the  liver  or  kidneys, 
i  On  the  other  hand  ether  is  said  to  be  somewhat  more  irritating 
to  the  respiratory  mucous  membranes. 

NITROUS  OXIDE 

Nitrous  oxide,  very  commonly  called  laughing  gas  is  used 
mostly  by  dentists  for  such  brief  work  as  tooth  extraction. 
When  mixed  with  oxygen  it  is  comparatively  safe,  in  even 
somewhat  longer  operations  and  is  often  used  for  curettage. 

COCAIN 

For  injection  cocain  is  usually  employed  in  a  one  or  two  per 
cent  solution.  As  an  ingredient  of  Schleisch  solution  it  is  used 
for  what  is  called  infiltration  anesthesia.  It  is  also  often  com- 
bined with  adrenalin  for  injection  or  application  to  the  mucous 
membrane.  In  applying  alone  to  the  mucous  membrane  it  is  used 
in  from  2  to  10  per  cent  solution.  A  pledget  of  cotton  is  dipped 
in  this,  applied  to  the  mucous  membrane  to  be  anesthetized,  and 
left  in  place  for  a  few  minutes. 


ANESTHETICS  AND  ANESTHESIA  75 

Dry  cocain  powder  is  sometimes  applied  to  the  mucous  mem- 
brane after  the  application  of  adrenalin.  This  is  frequently 
done  in  operations  upon  the  nose.  Toxic  effects  are  sometimes 
observed,  such  as  headache,  nausea,  vomiting,  weak  pulse, 
talkativeness,  or  delirium.  These  are  usually,  however,  of  no 
great  consequence. 

ETHYL  CHLORIDE 

This  is  a  highly  volatile  substance  which  is  sprayed  upon 
the  part  to  be  anesthetized.  By  a  rapid  evaporation  it  freezes 
the  part,  and  so  may  be  used  in  lancing  boils,  carbuncles,  etc. 


SURGICAL  AFTER-TREATMENT 

Kinds  of  Operations 

The  following  are  some  of  the  more  important  operations 
which  are  designated  by  special  terms:  The  list  is  necessarily 
very  incomplete. 

Arthrotomy.     The  incision  of  a  joint  cavity. 

Arthrectomy.  The  excision  of  the  articular  ends  of  the 
bones  entering  into  the  formation  of  the  joint. 

Appendectomy.     Removal  of  the  vermiform  appendix. 

Caesarean  section.  Removal  of  usually  living  child  by  ab- 
dominal incision. 

Cholecystectomy.     Excision  of  the  gall  bladder. 

Cholecystotomy.     Incision  of  the  gall  bladder. 

Cholecystostomy.  Incision  of  the  gall  bladder  with  forma- 
tion of  a  fistula. 

Curettage.  Scraping  of  a  cavity,  especially  the  uterine 
cavity. 

Enterorrhaphy.     Suture  of  the  intestines. 

Gastroenterostomy.  The  formation  of  a  fistula  between  the 
stomach  and  intestines. 

Herniotomy.     The  repair  of  a  hernia. 

Hysterectomy.     Excision  of  the  uterus. 

Laparotomy.  Abdominal  incis'on  for  any  operation  on  in- 
ternal organs. 

Lithotomy.  Incision  of  the  bladder  for  the  removal  of  the 
stone. 

Mammectomy.     Excision  of  the  breast. 

Nephrectomy.     Excision  of  the  kidney. 

Nephropexy.     Fixation  of  a  floating  kidney. 

Nephrorrhaphy.     Suture  of  the  kidney. 

Oophorectomy.     Removal  of  ovary. 

Oophorosalpingectomy.    Excision  of  an  oviduct  and  ovary. 

Oophorohysterectomy.     Excision  of  ovaries  and  uterus. 

Panhysterectomy.  Removal  of  uterus  and  all  its  append- 
ages. 

Perineorrhaphy.     Suture  of  the  perineum. 

Prostatectomy.     The  removal  of  the  prostate  gland. 


MAJOR  OPERATIONS  77 

Salpingectomy.     Excision  of  a  Fallopian  tube. 

Salpingooophorectomy.      Excision  of  an  oviduct  and  ovary, 

Thyroidectomy.     Excision  of  the  thyroid  gland. 

Tonsillectomy.     Excision  of  the  tonsils. 

Trachelorrhaphy.  Suturing  of  the  neck  of  the  uterus  (cer- 
vix uteri). 

Transfusion.  Transfer  of  blood  directly  into  the  veins  from 
one  person  to  another. 

Trephining.  Making  of  an  opening  thru  the  bones  of  the 
skull. 

Turbinectomy.  The  excision  of  a  portion  of  a  turbinate 
body. 

Major  Operations 

GENERAL  CARE 

1.  Keep  patient  quiet  and  warm. 

2.  Watch  the  pulse  almost  continuously  for  the  first  two  or 
three  hours  and  record  frequently.    Later  record  T.  P.  R.  every 
three  hours. 

3.  Measure  and  record  the  amount  of  urine.     Save  for  the 
first  24  hours  for  analysis,  and  afterwards  as  ordered. 

4.  Have  a  pus  tray  at  hand  in  case  of  nausea.     The  nurse 
may  resort  to  the  following  measures  for  the  relief  of  nausea 
without  an  order  from  the  physician:  — 

a.  Ice  bag  or  cold  compress  to  throat. 

b.  Inhalations  of  vinegar  or  camphor. 

5.  Place  cotton  pillows  under  the  knees  to  relieve  strain, 
also  have  pillows  of  different  shape  and  size  to  tuck  in  here  and 
there  to  make  the  patient  comfortable. 

6.  Keep  lips  moist  and  cleanse  mouth  frequently. 

7.  Water  drinking.    It  is  now  considered  good  therapy  and. 
in  general  highly  advisable  to  give  water  freely  in  small  amounts 
as  soon  as  the  patient  is  conscious.     A  glass  of  hot  water  is 
considered  best  at  first,   following  this  with  hot  or  cold  water 
as  the  patient  desires.     Ice  water  or  chipped  ice  should  not  be 
given  unless  ordered.    The  first  water  given  may  produce  vom- 
iting,  but  as  this  washes  out  the  stomach  and  hence  relieves 
nausea  and  vomiting,  it  is  considered  beneficial.     The  free  use 
of  water  aids  in  the  elimination  of  the  ether  and  helps  to  pre- 
vent kidney  complications. 

8.  Cathartics  and  enemata.     The  giving  of  cathartics  soon 


78  SURGICAL  NURSING 

after  operation  is  meeting  with  less  favor  than  formerly.    Cath- 
artics and  enemata  should  be  given  only  as  ordered. 
9.  Follow  strictly  all  the  orders  of  the  physician. 

10.  Watch  for  symptoms  of  shock,  or  other  complications 
that  are  liable  to  arise.     Watch  for  indications  of  hemorrhage, 
and  where  this  may  be  external,  inspect  the  dressings  over  the 
field  of  operation  very  frequently  and,  if  the  slightest  evidence 
is  seen,  report  at  once. 

11.  Do  not  fail  to  describe  accurately  all  discharges. 

12.  See  things  to  do  and  anticipate  the  needs  of  the  patient. 
Put  yourself  in  his  place,  and  do  your  best  to  make  him  just  as 
comfortable  as  possible. 

13.  Give  sponge  bath  or  similar  treatment  daily.    Soap  wash 
three  times  per  week. 

14.  Keep  bedding  dry  and  free  from  crumbs  and  wrinkles. 

15.  Give  preventive  treatment  for  bed  sores. 

16.  Dressing  of  wounds.     Before  the  hour  appointed  for  the 
dressing  of  a  wound  or  the  removal  of  stitches,  see  that  a  tray 
containing  the  following  articles  is  in  readiness:— 

a.  Package  of  sterile  napkins. 

b.  Small  bowl  of  disinfectant  and  one  of  sterile  water  or 
normal  saline,  if  needed. 

c.  Sterile  instruments.— Scissors,  artery  forceps,  thumb  for- 
ceps. 

d.  Package  of  small  sponges  and  also  <  ne  of  pledgets. 

e.  Package  of  dressings. 

The  nurse  places  a  table  by  the  bed  of  the  patient.  On  this 
she  places  newspapers  and  over  these  clean  towels.  On  the 
table  she  places  the  tray  of  disinfectant  for  the  hands.  She 
then  places  a  wastebasket  by  the  table  with  a  newspaper  in  the 
bottom. 

The  nurse,  after  scrubbing  her  own  hands,  unpins  the 
•bandage  and  turns  it  back.  Then  she  unties  the  tapes  holding 
the  dressing.  Next  she  unpins  the  sterile  packages  on  the  tray, 
turning  back  the  wrapper  containing  the  surgical  napkins,  so 
that  she  can  get  them  easily.  She  then  scrubs  her  hands  in 
disinfectants  on  the  table,  places  sterile  napkins  about  the 
wound,  turns  back  the  outer  dressing  (cotton  pad),  and  is  then 
ready  to  assist  the  surgeon.  She  is  very  careful  not  to  touch 
anything  that  is  surgically  clean  without  disinfecting  her  hands. 


MAJOR   OPERATIONS  79 

After  the  dressing,  the  nurse  ties  the  tapes  and  replaces 
the  bandages.  All  soiled  dressings  are  tied  up  in  the  news- 
papers at  the  bottom  of  the  wastebasket  and  burned.  The  tray 
is  then  returned  to  its  proper  place. 

The  above  is  a  description  of  an  average  dressing.  Under 
certain  conditions  many  other  things  may  be  needed  and  all 
these  are  to  be  ascertained  by  the  nurse.  She  must  ever  be  on 
the  alert  and  quickly  anticipate  the  needs  of  the  surgeon. 

17.  To  prepare  the  patient  for  removal  of  stitches  or  for  the 
changing  of  dressings,   see  first  that  all  necessary  articles  are 
in  readiness.     Move  the  patient  near  to  the  edge  of  the  bed. 
Unpin  the  bandage  and  turn  it  back.     Untie  the  tapes  over  the 
dressings,   and  surround  the  field  with  sterile  towels.     When 
ready,  it  is  usually  the  duty  of  the  nurse  to  remove  the  outer 
cotton  pad  so  that  the  surgeon  need  touch  nothing  not  likely  to 
be  sterile. 

18.  In  all  major  operations  the  patient  should  never  be  left 
alone  until  thoroly  conscious  and  responsible. 

ABDOMINAL  SECTION 

1.  Directly  after  operation  many  operators  order  a  warm 
enema  of  normal  salt  to  be  retained.     It  is  very  beneficial  be- 
cause it  relieves  the  thirst  which  follows  abdominal  operation, 
stimulates  the  kidneys,  and  has  a  general  stimulating  effect. 

2.  Do  everything  possible  to  encourage  the  passing  of  urine 
without  catheterization.     Use  the  catheter  only  when  ordered, 
and  always  with  the  strict  asccptic  precautions  as  a  cystitis  fol- 
lowing operation  is  unusually  troublesome. 

3.  The  accumulation  of  gas  is  quite  common  after  laparo- 
tomy.     To  relieve  this,  pass  a  rectal  tube  about  four  inches  and 
let  it  remain.     In  obstinate  cases  get  orders  from  the  surgeon. 
For  this  condition  the  saline,  asafoetida,  or  turpentine  enema 
is  frequently  used. 

4.  Allow  no  visitors  except  by  order  of  surgeon. 

5.  Slight  rise  of  temperature  the  day  following  is  very  com- 
mon, and  is  spoken  of  as  surgical  fever. 

6.  Allow  the  patient  to  sit  up  in  bed  or  to  walk  only  by 
order  of  the  surgeon. 

7.  Food  is  withheld  from  twenty-four  to  thirty-six  hours. 
During  the  first  week  a  liquid  diet  is  generally  used. 

8.  The  bowels  should  move  the  third  day. 


80  SURGICAL  NURSING 

9.  When  there  is  drainage  in  an  abdominal  wound  the  pa- 
tient is  obliged  to  stay  in  bed  three  or  four  weeks,  or  until  heal- 
ing takes  place.  When  first  allowed  to  get  up  he  should  be 
cautioned  against  any  exertion  such  as  lifting  or  stooping,  as 
any  strain  on  the  scar  may  produce  hernia. 

PERINEORRHAPHY  CASES 

1.  The  first  twenty-four  hours'  treatment  is  the  same  as  for 
abdominal  section. 

2.  The  bowels  should  move  once  daily  after  the  second  day. 

3.  Care  should  be  taken  that  the  stitches  are  not  torn  apart. 
Keep  the  knees  close  together. 

4.  Never  catheterize  without  orders. 

5.  Always  cleanse  the  parts  after  urination.     Spraying  of 
the  stitches  with  hot  saline  solution  or  the  alternate  hot  and 
cold  spray  is  very  beneficial.     Oftentimes  the  wound  is  washed 
off  with  sterilized  cotton  held  with  forceps  and  dipped  in  a  dis- 
infectant solution.     Wipe  dry  with  bits  of  cotton  held  in  the 
same  way,  and  apply  some  soothing  and  antiseptic  powder. 

6.  Dress  the  wound  according  to  the  order  of  the  surgeon. 
The  nurse  should  get  explicit  instruction  in  regard  to  this. 

7.  Watch  the  stitches  for  evidences  of  anything  that  may 
need  attention  from  the  surgeon. 

TRACHELORRHAPHY 

1.  Encourage  urination  without  the  use  of  the  catheter. 

2.  The  first  packing  is  usually  removed  on  the  second  day. 

3.  After   the   removal   of  the   packing,    hot    disinfectant 
douches  should  be  given  as  ordered. 

GALL  BLADDER  CASES 

In  cases  of  cholecystostomy,  that  is,  where  there  is  tempor- 
ary drainage  of  the  gall  bladder,  special  care  of  the  drainage 
tube  and  bottle  or  other  receptacle  for  the  bile,  is  required. 
See  that  the  bottle  is  so  placed  that  it  will  receive  the  bile  with- 
out soiling  of  the  dressings  or  bed  linen.  See  that  it  is  not  sus- 
pended alone  by  the  drainage  tube  but  is  fastened  to  the  abdom- 
inal bandage  by  tapes.  The  bottle  should  be  emptied  from 
time  to  time  as  is  necessary,  and  thoroly  cleansed  to  prevent 
the  unpleasant  odors  of  decomposing  bile.  After  the  removal 
of  the  drainage  tube,  which  usually  occurs  on  the  eighth  to  the 


SURGICAL  COMPLICATIONS  81 

eleventh  day,  the  dressings  have  to  be  changed  very  frequently. 
Large  pads  of  absorbent  cotton,  covered  with  gauze,  may  be 
provided  for  this  purpose.  The  excoriation  of  the  skin  about 
the  biliary  fistula  may  be  prevented  by  gentle  washing  away  of 
the  bile  and  the  application  of  a  very  small  amount  of  talcum 
powder.  In  case  there  are  additional  drainage  tubes  beside  that 
going  into  the  gall  bladder,  the  patient  must  remain  on  the  back 
until  the  openings  left  by  these  latter  have  entirely  closed. 

PROSTATECTOMY  CASES 

Prostatectomy  and  lithotomy  are  done  by  either  the  perineal 
or  the  suprapubic  route.  It  is  practically  always  necessary  to 
leave  in  the  bladder  a  double  flow  drainage  tube,  thru  which 
the  bladder  is  kept  constantly  irrigated  for  the  first  two  or 
three  days,  or  until  the  return  flow  ceases  to  be  bloody.  In 
case  clots  stop  the  opening  in  the  larger  return  tube,  it  will  be 
necessary  to  aspirate  them  by  the  reverse  action  of  a  piston 
syringe.  The  irrigating  can  should  be  just  high  enough  to 
secure  an  easy  flow  without  undue  pressure.  At  intervals  the 
bladder  is  irrigated  with  some  antiseptic  solution,  such  as 
1 — 20,000  silver  nitrate.  In  these  cases  about  15  gr.  urotropin 
daily  is  administered  by  mouth  in  divided  doses.  It  is  a  very 
efficient  and  practically  the  only  reliable  urinary  antiseptic. 

Because  of  the  fact  that  this  operation  is  always  done  in 
old  men,  the  patient  is  encouraged  to  sit  up  as  soon  as  possible, 
and  even  before  that  he  should  be  allowed  to  turn  from  side  to 
side  so  as  to  prevent  hypostatic  pneumonia. 

CASES  OF  ABSCESS  DRAINAGE 

In  cases  where  an  abdominal  or  pelvic  abscess  has  been 
drained,  the  use  of  continuous  proctoclysis  by  the  Murphy 
method  is  highly  recommended.  If  the  constant  presence  of 
the  tube  in  the  rectum  is  overly  irritating,  the  saline  solution 
may  be  given  by  intermittent  proctoclysis — a  half  pint  or  more 
at  a  time.  This  not  only  helps  to  maintain  blood  pressure,  but 
is  said  to  have  a  very  beneficial  effect  in  flushing  the  drained 
surfaces  thru  the  absorbents.  The  directions  for  proctoclysis 
are  given  elsewhere. 

Surgical  Complications 

SURGICAL  SHOCK 

Surgical  shock  and  hemorrhage  are  the  two  most  serious 
6 


82  SURGICAL  NURSING 

surgical  complications  which  occur  on  the  operating  table.  The 
symptoms  of  the  two  are  very  much  alike;  that  is,  weak,  thready 
pulse  and  cold,  clammy  skin.  With  the  treatment  of  hemor- 
rhage on  the  operating  table  the  nurse  has  very  little  to  do, 
with  the  exception  of  assisting  in  the  giving  of  saline  solution 
by  hypodermoclysis,  or  possibly  very  rarely  by  direct  vein  in- 
fusion. Following  the  operation  where  the  patient  has  lost 
much  blood,  the  surgeon  frequently  orders  saline  solution  by 
continuous  proctoclysis.  The  method  of  giving  this  is  described 
elsewhere. 

In  case  of  surgical  shock  much  of  the  treatment  may  be 
carried  out  by  the  nurse  directly  under  the  physician's  direc- 
tion. The  condition  is  said  to  be  due  most  largely  to  a  tempor- 
ary paralysis  of  the  vasomotor  center.  Various  other  theories 
are  given,  with  which  we  need  not  concern  ourselves  here. 
Surgical  shock  very  readily  responds  to  vigorous  cutaneous 
stimulation  by  means  of  briefly  applied  hot  applications  quickly 
followed  by  the  cold  mitten  friction.  This  may  be  carried  out 
by  the  following  plan:— 

"The  effectual  treatment  of  shock  requires  the  attention 
of  two  persons.  On  the  appearance  of  the  symptoms  of  shock, 
immediately  place  the  patient's  feet  in  hot  water,  care  being 
taken  that  the  water  is  not  nearly  hot  enough  to  produce  a 
burn;  or  quickly  apply  well- wrapped  fomentations  so  as  to 
cover  both  feet  and  legs  to  the  knees.  As  soon  as  the  parts 
have  been  well  warmed  and  reddened,  remove  the  hot  applica- 
tion and  quickly  administer  to  the  same  parts  a  cold  mitten 
friction.  The  water  used  should  be  ice  water,  and  the  friction 
most  vigorously  given.  The  mitts  should  be  dipped  2  or  even 
3  times,  another  attendant  holding  the  limb  while  it  is  being 
treated.  The  skin  is  now  dried  and  rubbed  with  a  coarse 
Turkish  towel  and  immediately  covered  with  a  warm  dry 
blanket.  The  thighs  should  be  treated  in  the  same  manner, 
also  the  arms.  While  this  is  being  done  and  beginning  at  the 
same  time  as  the  first  treatment  to  the  limbs,  intense  and 
quickly  alternating  hot  and  cold  applications  should  be  made  to 
the  anterior  surface  of  the  chest  and  especially  over  the  pre- 
cordia.  This  may  be  done  by  removing  the  ice  bag  from  the  pre- 
cordia,  which  should  have  been  placed  there  when  the  pulse 
first  became  unduly  rapid,  and  after  rubbing  the  skin  briskly, 
applying  a  very  hot  but  well  covered  fomentation.  This  should 


SURGICAL  COMPLICATIONS  83 

not  be  left  in  contact  with  the  skin  longer  than  15  or  30  seconds. 
Next,  rub  the  chest  with  a  flat  smooth  piece  of  ice,  using  quick 
to-and-fro  movements  and  wiping  away  the  water  with  a  Turk- 
ish towel.  After  this  another  fomentation  is  applied,  again 
followed  by  the  ice.  These  alternations  should  be  repeated  3  or 
4  times,  after  which  the  well-covered  ice  bag  should  again  be 
placed  over  the  heart,  "i 

In  addition  to  the  above,  administer  8  oz.  to  1  pint  of  hot 
saline  solution  by  hypodermoclysis  or  by  rectal  injection,  or  both. 

The  hypodermic  use  of  strychnin  and  other  '  'heart  stimu- 
lants" has  been  shown  to  be  productive  of  more  harm  than 
good,  and  results  in  a  deeper  degree  of  shock.  This  is  partic- 
ularly true  of  strychnin,  as  it  is  an  irritant  to  the  vasomotor 
center. 

HEMORRHAGE 

While  the  nurse  has  very  little  to  do  with  the  treatment  of 
hemorrhage  on  the  operating  table,  in  case  the  hemorrhage 
occurs  after  the  removal  to  the  room,  the  life  of  the  patient  may 
be  dependent  upon  the  keen  observation  and  prompt  action  of 
the  nurse  in  charge.  Hemorrhage  following  operation  usually 
occurs  within  the  first  few  hours,  altho  it  may  occur  later. 
Those  cases  which  are  most  serious  are  where  the  hemorrhage 
is  internal,  so  that  the  field  of  operation  and  dressings  give 
no  indication  of  the  condition.  It  is  well,  however,  to  keep 
close  watch  of  the  dressings  during  the  first  six  or  eight  hours 
following  operation.  Internal  hemorrhage  is  marked  by  a  sud- 
den fall  in  the  temperature,  rapid,  thready  pulse,  and  a  profuse 
cold  sweat.  There  are  also  pallor,  thirst,  an  anxious  expres- 
sion, and  faintness.  If  the  patient  has  come  out  from  under  the 
anesthetic  the  eyes  may  be  bright  and  the  mind  clear.  If  these 
symptoms  appear,  the  surgeon  should  be  summoned  at  once. 
In  the  mean  time  the  head  should  be  kept  low,  in  some  cases 
the  foot  of  the  bed  raised.  The  patient  should  be  kept  abso- 
lutely quiet,  and  heat  applied  to  the  extremities.  It  is  usually 
best  not  to  stimulate  the  circulation  to  any  great  degree  until 
after  the  hemorrhage  is  stopped.  Following  this  a  saline  enema, 
continuous  proctoclysis,  hypodermoclysis,  and  water  drinking 
are  the  measures  necessary  to  supply  the  loss  of  fluid.  In  the 
event  of  any  serious  complication,  as  hemorrhage,  the  nurse 
should  maintain  the  utmost  quiet  and  calm.  Nothing  is  to  be 

1.  Abbott,  "Hydrotherapy,"  p.  232. 


84  SURGICAL  NURSING 

gained  by  informing  the  patient  of  his  condition  or  allowing 
him  to  observe  any  anxiety  on  the  part  of  the  nurse. 

WOUND  INFECTION 

1.  Superficial  infection  and  stitch  abscess.    Bacteria  are  prac- 
tically always  present  in  the  epidermis,  so  that  it  is  a  very  dif- 
ficult matter  to  prepare  a  field  that  is  absolutely  devoid  of  bac- 
teria.    The  most  common  germ  is  the  staphylococcus  albus. 
Under  certain  conditions  this  germ  multiplies  and  produces  more 
or  less  difficulty  with  healing.     Among  the  conditions  favoring 
skin  infection  are  bruising  of  the  tissues  either  in  the  prepara- 
tion of  the  operative  field  or  in  the  operative  technique.     Very 
tightly  tied  sutures  are  also  sometimes  responsible  for  an  in- 
fection. 

Perhaps  the  most  common  cause  of  wound  infection  is  low 
vitality  of  the  tissues  themselves.  The  collection  of  blood  un- 
derneath the  skin  or  between  the  edges  of  the  wound  may  also 
give  rise  to  infection.  Sometimes  infection  may  be  present 
without  giving  rise  to  symptoms.  Generally,  however,  there  is 
slight  pain  in  the  wound  and  a  moderate  rise  of  temperature. 
Upon  inspection  of  the  wound  surface  swelling  and  redness  are 
usually  detected.  Infection  generally  occurs  somewhere  from 
the  third  to  the  seventh  day  following  operation.  As  wound 
infections  are  always  attended  to  by  the  surgeon,  the  nurse  has 
very  little  to  do,  with  the  exception  of  calling  attention  to  any- 
thing that  may  appear  suspicious.  Careful  note  of  these  items 
should  also  be  made  on  the  record. 

A  stitch  abscess  may  be  due  to  germs  present  on  the  skin 
surface,  irritation  caused  by  the  suture  material,  or  to  imper- 
fectly sterilized  sutures.  Where  stitch  abscess  occurs,  it  is 
necessary  to  remove  the  stitch.  Stitch  abscesses  are  usually  of 
no  great  consequence. 

2.  Deep  infection.     Of  the  various  causes  of  deep  infection 
poorly  prepared  sutures,  especially  catgut,   are  frequent;  also 
the  collection  of  blood  or  serum  thru  imperfect  hemostasis  or 
wound  drainage.     In  operations  upon  infected  organs  some  of 
the  pus  or  secretions  may  soil  the  wound  surface.     In  deep  in- 
fections there  is  a  rise  of  temperature,  usually  between  101  and 
103  degrees.     There  is  greater  pain  and  swelling  than  in  super- 
ficial infections.     These  may  occur  within  4  or  5  days,  or  even 
as  late  as  the  second  week. 


SURGICAL  COMPLICATIONS  85 

Deep  infections  are  always  to  be  cared  for  by  the  surgeon. 
Usually  the  nurse  in  such  event  is  only  to  follow  very  closely 
any  special  instructions  that  may  be  given. 

PNEUMONIA 

Pneumonia  was  formerly  supposed  to  be  more  frequent 
after  the  use  of  ether  than  of  chloroform,  but  with  ether  given 
by  the  modern  drop  method  this  statement  is  hardly  applicable. 
The  most  important  causes  of  pneumonia  following  an  operation 
are:  congestion  of  the  lungs  due  to  the  exposure  of  the  patient 
on  the  operating  table  or  soon  after,  prolonged  operations,  opera- 
tions upon  aged  patients,  and  long  confinement  in  the  dorsal 
position  following  operation.  It  is  perhaps  unnecessary  to  men- 
tion that  pneumonia  is  very  common  in  those  patients  who  have 
previously  had  some  infection  of  the  respiratory  tract.  Pneu- 
monia should  be  very  carefully  guarded  against  by  seeing  that 
the  patients  limbs  and  chest  are  well  covered  during  the  opera- 
tion, and  especially  that  the  feet  are  warm;  also  that  proper 
jackets  are  used  following  the  operation.  After  the  patient  has 
been  removed  from  the  operating  table  it  is  an  excellent  plan 
to  make  some  hot  application  to  the  feet  and  legs,  such  as  a  hot 
foot  bath,  fomentations,  or  the  hot  pack.  Some  surgeons  highly 
recommend  the  use  of  the  ice  bag  or  cold  coil  to  the  chest, 
shoulders  and  all  other  parts  being  well  covered  during  its  ap- 
plication. This  other  is  not  applicable  in  old  people  nor  in  those 
under  average  vitality,  and  is  best  applied  during  the  applica- 
tion of  the  heat  to  the  feet  and  legs. 

The  onset  of  pneumonia  may  be  marked  by  frequent  res- 
piration, pain,  and  a  rise  of  temperature,  together  with  undue 
rapidity  of  the  pulse.  It  may  occur  within  24  or  36  hours  after 
the  operation  or  be  delayed  as  long  as  two  or  three  weeks. 

PERITONITIS 

The  onset  of  peritonitis  is  marked  by  pain  and  extreme 
tenderness  in  the  abdomen.  The  abdomen  is  likely  to  be  dis- 
tended with  gas  (tymanites),  the  limbs  are  drawn  up,  and  the 
pulse  becomes  rapid  and  wiry.  The  beginning  of  a  rise  of  tem- 
perature from  101  to  103  may  be  marked  by  chills  or  chilly  sen- 
sations. There  is  often  vomiting,  and  the  constipation  is  ob- 
stinate. The  patient  is  restless,  and  complains  of  feeling  very 
weak. 


86  SURGICAL  NURSING 

In  all  cases  the  treatment  will  be  directed  by  the  surgeon. 
Among  the  measures  that  are  used  are  the  warm  enema,  and 
in  case  of  pelvic  peritonitis  a  hot  vaginal  douche  is  frequently 
prescribed.  Perhaps  the  most  efficient  measure  is  the  applica- 
tion of  the  hot  hip  and  leg  pack,  with  one  or  more  ice  bags  to 
the  abdomen.  This  usually  lasts  about  thirty  minutes  and  is 
followed  by  a  cold  mitten  friction  to  all  parts  covered  by  the  hot 
applications,  with  the  exception  of  the  abdomen.  This  may 
need  to  be  repeated  two  or  three  times  a  day.  The  ice  bags  to 
the  abdomen  are  often  left  in  place  between  treatments.  All 
directions  should  be  very  carefully  followed,  as  the  mortality  of 
peritonitis  following  operation  is  very  high. 

INTESTINAL  OBSTRUCTION 

Intestinal  obstruction  is  usually  first  indicated  by  pain  in 
the  abdomen,  or  tympanites.  The  pulse  may  first  be  increased 
in  tension,  but  later  becomes  very  rapid  and  weak.  Soon  after 
the  appearance  of  pain  vomiting  begins,  first  of  food  and  later 
of  fecal  matter.  Obstipation  is  always  present.  The  appear- 
ance of  pain  and  tympanites,  and  always  the  appearance  of  un- 
controllable vomiting,  should  be  indications  for  prompt  notifica- 
tion of  the  surgeon.  In  conditions  where  the  character  of  the 
operation  does  not  make  it  inadvisable,  the  thoro  cleansing  of  the 
bowels  by  soapsuds  enema  followed  by  the  giving  of  a  glycerine 
epsom  salts  enema  by  high  bowel  catheter,  is  usually  ordered. 
All  these  treatments  should  be  very  carefully  but  persistently 
carried  out. 

SEPTICEMIA 

Septicemia  is  a  general  toxic  condition  caused  by  the  ab- 
sorption of  septic  products.  Its  onset  is  marked  by  severe 
chills,  which  may  be  repeated,  high,  irregular  fever  (intermit- 
tent type),  rapid,  bounding  pulse,  sometimes  also  by  vomiting. 
The  treatment  varies  according  to  the  source  and  location  of 
the  infection.  Such  hydriatic  treatments  as  cold  mitten  friction, 
which  increases  leucocytosis,  are  highly  beneficial.  Friction  or 
massage  should  never  be  applied  to  any  part  immediately  in- 
volved. 

CYSTITIS 

Cystitis  is  an  inflammation  of  the  bladder.  It  is  often 
caused  by  an  infection  carried  in  by  a  catheter,  altho  it  may  be 
due  to  other  causes,  such  as  a  pre-existing  infection. 


SPECIAL  PROCEDURES  87 

Pain  over  the  pubes,  painful  and  frequent  micturition,  are 
evidences  of  its  existence.  The  urine  is  usually  cloudy  from 
presence  of  bacteria,  and  in  some  cases  may  contain  more  than 
small  amounts  of  mucus  and  pus.  When  cystitis  occurs,  uro- 
tropin  is  usually  ordered,  also  hot  boric  acid,  bladder  irrigations, 
or  the  use  of  other  mild  antiseptic.  Fomentations  to  the  lower 
abdomen  and  pubic  region  afford  much  relief  by  relaxing  the 
the  spasm  of  the  bladder. 

There  are  many  other  complications  that  may  arise  in  sur- 
gical cases.  Among  the  more  serious  of  these  are  uremia,  teta- 
nus, erysipelas,  and  pyemia.  Fortunately,  however,  the  latter 
three  are  very  rare. 

Procedures  of  Special  Use  in  Surgical  Nursing 

HYPODERMOCLYSIS 

Definition.  The  hypodermic  injection  of  large  amounts  of 
fluid.  Hypodermocbsis  is  usually  given  over  the  chest,  ab- 
domen, thigh,  arm,  or  between  the  shoulder  blades. 

1.  Articles  needed:— 

a.  Irrigator,  preferably  a  glass  one  that  is  graduated. 

b.  Two  long  hypodermic  needles. 

c.  Tubing. 

d.  Sterile  normal  salt  solution. 

e.  Collodion. 

f .  Small  beaker  of  alcohol. 

g.  Package  of  sterile  cotton  pledgets, 
h.  Package  of  sterile  napkins. 

i.  Bowl  of  disinfectant  for  hands. 

2.  Procedure.     It  is  absolutely  necessary  that  all  the  ap- 
paratus used  be  properly  sterilized.     This  is   generally  kept 
sterile  and  ready  for  use  at  a  moment's  notice. 

After  the  tray  is  set  and  everything  ready,  the  one  who  is 
to  give  the  hyyodermoclysis  scrubs  up  thoroly.  She  then  scrubs 
with  alcohol  the  part  where  the  needle  is  to  be  inserted.  Next 
the  hands  are  disinfected  and  the  sterile  napkins  placed  about 
the  area.  Then  the  solution  is  allowed  to  run  thru  the  needle 
so  as  to  exclude  all  air,  and  then  the  needle  is  inserted. 

If  given  in  the  breasts,  it  is  a  good  plan  to  connect  the  ap- 
paratus so  as  to  give  it  in  both  breasts  simultaneously.  For 
this  two  needles  will  be  required.  From  500  to  1000  c.c.  of 
physiologic  salt  solution  are  generally  injected  at  a  time. 


88  SURGICAL  NURSING 

When  the  amount  of  solution  desired  has  passed  into  the 
tissues  the  needles  are  carefully  withdrawn  and  the  point  of 
insertion  sealed  with  cotton  and  collodion. 

INTRAVENOUS  SALINE  INFUSION 

This  is  always  done  by  a  physician. 

1.  Indications:— 

a.  Shock. 

b.  Loss  of  large  amount  of  blood. 

c.  Suspension  of  the  functions  of  the  kidneys. 

d.  Toxins  in  the  blood  where  rapid  elimination  is  desired  as 
in  septicemia  and  delirium  tremens,  also  diabetic  coma. 

2.  Technique.    Area.    Median  basilic  or  the  median  cephalic 
vein  at  the  bend  of  the  elbow. 

A  constricting  bandage  is  placed  around  the  upper  part  of 
the  arm  so  as  to  obstruct  the  return  flow  thru  the  superficial 
veins.  The  skin  over  inner  surface  of  elbow  is  disinfected 
thoroly  and  the  vein  is  bared  and  cleared  for  about  one  inch. 
Two  ligatures  are  passed  around  it,  one  above  the  point  of  in- 
tended opening  and  one  below.  A  small  valve-like  opening  is 
then  made  in  the  vein,  and  a  small  irrigator  point  is  introduced, 
first  allowing  some  of  the  fluid  to  pass  thru  it,  in  order  to  guard 
against  the  entrance  of  air.  The  upper  ligature  is  tightened 
around  the  irrigator  point,  holding  it  in  place  and  also  prevent- 
ing leakage. 

The  lower  ligature  is  tied,  closing  the  vein  below.  The 
bandage  is  now  removed. 

The  jar  containing  solution  should  be  about  three  feet  above 
vein.  The  solution  generally  used  is  a  physiologic  salt  so- 
lution. 

After  a  sufficient  amount  of  solution  has  been  introduced 
into  the  blood,  the  skin  is  sutured  and  a  sterile  dressing  applied 
and  held  by  adhesive.  Every  precaution  is  taken  in  this  pro- 
cedure to  have  all  apparatus,  field  of  operation,  dresssings,  etc., 
surgically  clean. 

PROCTOCLYSIS 

Proctoclysis  is  administered  for  the  purpose  of  steady, 
gradual  introduction  of  fluid  into  the  system.  The  large  bowel 
will  absorb  in  the  neighborhood  of  two  to  three  pints  in  the 
course  of  two  hours.  It  is  given  chiefly  after  the  institution  of 
pelvic  or  abdominal  drainage  for  abscess,  but  is  also  of  great 


SPECIAL  PROCEDURES  89 

benefit  in  hemorrhage  and  following  shock.  The  fluid  should 
be  administered  thru  a  fountain  syringe  to  which  is  attached  a 
three-eights  inch  rubber  hose  with  a  hard  rubber  or  glass  vagi- 
nal douche  tip  with  multiple  openings.  This  tube  should  be 
flexed  almost  to  right  angles,  three  inches  from  its  tip.  A 
straight  tube  must  not  be  used,  as  the  tip  produces  pressure  on 
the  posterior  wall  of  the  rectum  when  the  patient  is  in  the  Fow- 
ler's position.  The  tube  is  inserted  into  the  rectum  to  the 
flexion  angle  and  secured  in  place  by  adhesive  strips,  binding  it 
to  the  side  of  the  thigh  so  that  it  can  not  come  out;  the  rubber 
tubing  is  passed  under  the  bedding  to  the  head  or  foot  of  the 
bed,  to  which  the  fountain  is  attached. 

Two  or  three  inches  from  the  fountain  syringe  interpose  a 
Y-tube,  and  to  the  upper  limb  attach  a  piece  of  rubber  hose  of 
the  same  size  as  the  outlet  tube.  Fasten  the  free  end  of  this  to 
the  top  of  the  fountain  syringe  so  that  what  returns  thru  it 
will  fall  into  the  container.  When  flatus  is  voided,  the  gas 
passes  more  readily  thru  the  upper  tube  than  directly  into  the 
fountain  syringe.  This  reduces  the  pressure  at  such  times  and 
so  aids  in  preventing  expulsion  of  the  fluid  onto  the  linen. 

The  fountain  syringe  should  be  suspended  from  six  to 
fourteen  inches  above  the  level  of  the  buttocks  and  raised  or 
lowered  to  just  overbalance  hydrostatically  the  intra- abdominal 
pressure,  i.  e.,  it  must  be  just  high  enough  to  require  from 
forty  to  sixty  minutes  for  one  and  one-half  pints  to  flow  in,  the 
usual  quantity  given  every  two  hours.  The  flow  must  be  con- 
trolled by  gravity  alone,  and  never  by  a  forceps  or  constriction  on 
the  tube,  sc  that  when  the  patient  endeavors  to  void  flatus  or 
strain,  the  fluid  can  rapidly  flow  back  into  the  can,  otherwise  it 
will  be  discharged  in  the  bed.  It  is  this  ease  of  flow  to  and  from 
the  bowel  that  insures  against  over-distension  and  expulsion  onto 
the  linen. 

The  fountain  had  better  be  glass  or  graded  can,  so  that  the 
flow  can  be  estimated.  The  temperature  of  the  water  in  the 
fountain  can  be  maintained  at  100°  by  encasement  in  hot  water 
bags.  The  fountain  is  refilled  every  two  hours  with  one  and 
one-half  to  two  pints  of  solution.  Instead  of  the  usual  solution, 
a  teaspoonful  of  calcium  chloride  may  be  added  to  the  pint  of 
saline  solution.  The  tube  should  not  be  removed  for  two  or 
three  days  if  necessary,  i 

1  Abbott,  "Hydrotherapy,"  pp.  294,  295. 


ACCIDENTS  AND  MINOR  SURGERY 

Wounds 

Wounds  are  of  various  kinds,  and  according-  to  the  instru- 
ment causing  the  wound  and  the  character  of  the  wound  itself, 
they  may  roughly  be  classified  as  fellows:  contusions,  contused 
wounds,  incised  wounds,  lacerated  wounds,  punctured,  poisoned, 
infected,  and  gunshot  wounds. 

CONTUSIONS 

Contusions  are  not  necessarily  associated  with  breaking  or 
opening  of  the  skin.  They  are  commonly  spoken  of  as  bruises, 
and  are  wounds  of  soft  tissues  caused  by  blows,  etc.  If  taken 
early,  these  should  be  first  treated  by  the  application  of  the  ice 
bag  or  cold  compress,  to  prevent  the  undue  extravasation  of 
blood  into  the  tissues.  Later  on,  they  are  best  treated  by  alter- 
nate applications  of  heat  and  cold,  in  order  to  favor  the  absorp- 
tion of  the  blood  and  restore  the  vitality  of  the  tissues.  In  ap- 
plying the  cold  in  the  first  stage,  it  is  often  beneficial  to  use 
running  cold  water,  as  it  is  more  grateful  than  the  cold  com- 
press. 

CONTUSED  WOUNDS 

These  are  actual  breaks  in  the  tissue  accompanied  by  bruis- 
ing. There  is  always  more  or  less  hemorrhage  into  the  surround- 
ing tissues,  while  some  tissue  nearest  the  break  in  the  skin  has 
been  crushed  and  must  be  removed.  It  is  also  necessary  to 
thoroly  cleanse  the  wound  from  dirt  and  foreign  matter.  It  is 
well  also  to  apply  some  mild  antiseptic  at  first,  and  it  may  be 
necessary  to  wash  with  antiseptics  at  intervals  to  keep  the 
wound  from  suppurating.  Applications  of  heat  and  cold  may 
be  made  in  much  the  same  manner  as  with  simple  contusions, 
altho  it  is  well  in  cleansing  the  wound  to  use  warm  or  hot  water. 
Ointments  are  usually  best  omitted,  and  the  wound  dressed  with 
either  very  mild  antiseptic  solutions  or  dried  and  treated  with 
powder,  etc. 

INCISED    WOUNDS 
These  are  simply  plain  cuts  without  bruising  or  laceration 


WOUNDS  91 

of  the  tissue.  Where  they  are  large  and  the  edges  gap,  stitches 
should  be  used.  Before  stitches  are  applied,  or  in  case  the 
wound  is  too  small  to  require  sutures,  the  surface  should  be 
thoroly  cleansed  and  desinfected,  after  which  they  should  be 
dressed  with  plain  sterile  gauze. 

LACERATED  WOUNDS 

A  lacerated  wound  is  a  wound  in  which  the  tissues  have 
been  torn  and  show  many  ragged  edges.  These  are  often  so 
poorly  supplied  with  blood  as  to  slough  away  in  a  few  days. 
Lacerated  wounds  are  most  frequently  caused  by  accidents  with 
machinery,  dull  tools,  etc.  All  ragged,  torn  edges  should  be 
trimmed  off  with  scissors  or  knife  so  that  the  surfaces  are 
smooth.  They  should  then  be  washed  and  cleansed  with  anti- 
septic solutions  the  same  as  with  contused  wounds.  They  may 
also  need  to  be  dressed  with  very  weak  antiseptic  solutions  from 
time  to  time,  otherwise  it  is  well  to  keep  the  parts  as  dry  as 
possible,  as  wounds  heal  better  and  the  epithelium  grows  over 
the  surface  much  more  rapidly  where  this  is  done. 

Because  of  the  laceration  of  the  tissue  there  are  often  little 
recesses  where  germs  may  lodge  and  grow.  Where  such  lacer- 
ated wounds  are  received  because  of  blank  cartridges  and  other 
Fourth  of  July  ' "paraphernalia,"  or  where  soiled  with  street 
dust,  it  is  best  to  wash  thoroly  with  peroxide  of  hydrogen,  in- 
jecting it  into  all  possible  recesses  so  as  to  prevent  growth  of 
the  tetanus  germ. 

PUNCTURED  WOUNDS 

Punctured  wounds  are  most  frequently  due  to  pins,  nails, 
tacks,  thorns,  etc.  These  are  often  harmless  and  require  no 
treatment  whatever.  On  the  other  hand  they  are  occasionally 
the  source  of  very  grave  difficulties  such  as  blood  poisoning  and 
lock  jaw  (tetanus).  For  this  reason  if  the  instrument  or  object 
causing  the  wound  is  known  or  suspected  to  be  dirty,  the  wound 
should  be  most  thoroly  treated.  Germs  are  carried  into  the 
tissues  often  to  quite  a  depth.  Since  the  sharp  point  leaves 
very  little  opening  the  germs  grow  very  rapidly  at  the  depth 
away  from  the  air,  and  in  case  of  nail  punctures  of  the  foot  are 
very  likely  to  be  the  cause  of  lock  jaw.  Since  the  germ  of  teta- 
nus will  not  grow  in  the  presence  of  oxygen,  if  the  wound  is 
deep  it  is  well  to  lay  it  open  by  means  of  a  knife  and  thoroly 


92  SURGICAL  NURSING 

inject  with  peroxide  of  hydrogen.  This  liberates  oxygen  in 
the  wound  and  so  prevents  the  growth  of  the  tetanus  germ. 
Nail  punctures  acquired  about  a  barn  yard  are  especially  dan- 
gerous, as  tetanus  germs  are  much  more  numerous  in  such 
places.  If  there  seems  to  be  the  least  danger  from  this  source, 
the  person  having  the  wound  should  be  given  injections  of 
tetanus  antitoxin,  as  a  prophylactic. 

GUNSHOT  WOUNDS 

Whether  received  in  the  head,  trunk,  or  limbs,  these  wounds 
are  always  serious,  and  especially  so  when  they  involve  vital 
organs.  The  item  of  first  importance  is  to  stop  all  visible  hem- 
orrhage and  use  means  to  overcome  shock,  if  it  be  present.  The 
person  should  be  kept  at  rest  and  the  surgeon  summoned  at 
once.  Internal  hemorrhage  often  continues  in  these  wounds 
especially  when  received  in  the  chest  or  abdomen.  Where  symp- 
toms of  internal  hemorrhage  make  their  appearance,  and  there 
is  no  surgeon  at  hand,  it  is  best  to  bandage  the  limbs  next  to 
the  body  in  order  .to  prevent  undue  loss  of  blood.  Also  lower 
the  head  of  the  patient,  to  prevent  enemia  of  the  brain  and 
fainting.  The  application  of  ice  directly  over  the  wound  may 
in  some  cases  stop  the  hemorrhage  or  prevent  excessive  hem- 
orrhage. Foreign  particles  and  pieces  of  clothing  should  be 
removed  from  the  wound,  and  antiseptics  applied  over  the  sur- 
face to  prevent  further  infection. 

POISONED  WOUNDS 

This  term  may  very  conveniently  be  applied  to  wounds  in- 
flicted by  insects,  the  bites  of  dogs,  snakes,  and  other  animals. 
In  case  of  bites  by  venomous  snakes,  return  circulation  should 
be  shut  off  by  tight  bandage  close  above  the  wound.  As  it  will 
take  a  few  minutes  to  do  this,  the  part  should  be  quickly  grasped 
by  the  hands  and  held  so  tightly  as  to  prevent  all  return  of  the 
blood.  At  the  same  time  the  poison  and  blood  should  be  sucked 
out  of  the  wound  and  this  sucking  repeated  several  times  so  as 
to  get  rid  of  all  the  poison  that  it  is  possible  to  remove  in. this 
way.  It  is  well  to  rinse  out  the  mouth  afterward,  altho  the 
venoms  are  usually  inert  in  the  alimentary  tract.  The  wound 
may  now  be  treated  by  peroxide  of  hydrogen  or  rubbing  into  it 
crystals  of  permanganate  of  potash.  These  agents  oxidize  the 
poisons  and  so  render  them  harmless.  Cauterization  either 


WOUNDS  93 

with  a  hot  iron  or  chemical  agents  is  always  recommended  in 
order  to  destroy  the  venom.  In  the  case  of  bites,  the  stings  of 
bees,  wasps,  centipeds,  terantulas,  spiders,  etc.,  remove  the 
sting  and  apply  ammonia  water  and  then  a  cold  compress.  The 
harmful  effects  are  usually  in  proportion  to  the  individual  sus- 
ceptibility. Some  persons  have  a  special  predisposition  to  much 
pain  and  excessive  swelling  following  the  bites  of  certain  insects 
or  spiders. 

INFECTED  WOUNDS 

The  symptoms  of  infection  usually  appear  in  two,  three,  or 
four  days.  Infection  of  wounds  is  most  common  where  the 
instrument  or  object  inflicting  the  wound  is  dirty.  Sometimes 
these  are  found  in  spicules  of  bone,  butchers'  knives,  etc., 
where  men  are  working  in  packing  houses,  nail  punctures,  and 
scratches  from  thorns,  etc.  There  is  pain,  redness,  swelling, 
and  the  feeling  of  heat  in  the  part.  This  condition  is  usually 
spoken  of  as  blood  poisoning,  altho  this  term  had  perhaps  better 
be  reserved  for  something  more  than  local  infection.  Real  blood 
poisoning  (septicemia)  is  indicated  by  the  extension  of  red  lines 
centrally  from  the  infected  part.  These  are  due  to  the  spread 
of  the  bacteria  and  the  extension  of  the  infection  along  the  lym- 
phatics. They  are  signals  of  immediate  danger,  and  whenever 
they  appear  the  infected  part  should  be  most  vigorously  treated. 
The  wound  should  be  kept  open,  and  where  there  are  indications 
of  pus  it  may  be  necessary  to  make  additional  incisions.  The 
part  should  then  be  treated  by  alternate  hot  and  cold  pours  or 
immersion.  This  should  be  carried  out  by  means  of  the  hottest 
water  that  it  is  possible  to  be  born  on  the  skin,  and  the  tem- 
perature increased  from  time  to  time  to  the  limit  of  duration. 
Cold  applications  should  consist  of  ice  water;  chunks  of  ice 
should  be  kept  in  the  water  used.  In  the  case  of  hot  and  cold 
immersion,  the  part  should  be  left  in  the  hot  water  about  two 
minutes  and  placed  in  the  cold  for  twenty  or  thirty  seconds.  It 
should  then  be  returned  to  the  hot  for  two  minutes  and  again 
in  the  cold  for  twenty  or  thirty  seconds.  These  alternations 
should  be  kept  up  from  thirty  minutes  to  an  hour  at  a  time,  and 
repeated  from  one  to  four  times  daily  until  the  infection  is 
under  control.  In  case  of  the  hot  and  cold  pour,  the  duration 
of  each  phase  may  be  somewhat  less  than  that  mentioned  above. 


94  SURGICAL  NURSING 

Burns 

A  burn  is  an  injury  or  destruction  of  the  skin  or  deeper 
tissues  caused  by  dry  heat,  chemical  agents,  or  electricity. 
Scald  is  the  same  kind  of  injury,  differing  from  a  burn  by  being 
produced  by  hot  vapors  or  hot  liquids.  Burns  covering  a  small 
area  usually  cause  no  great  difficulty  other  than  the  immediate 
pain  and  discomfort.  Extensive  burns,  especially  those  cover- 
ing more  than  1/2  of  the  body  surface  are  likely  to  be  followed 
by  death.  This  is  said  to  be  due  to  the  destruction  of  the  nerves 
in  the  skin  which  govern  the  production  and  elimination  of  heat, 
also  to  internal  congestion,  and  occasionally  to  ulcerations  in  the 
internal  organs.  These  latter,  however,  are  the  later  results. 
Ulcerations  following  burns  are  not  uncommon  in  the  stomach 
and  intestines.  Sometimes  the  immediate  shock  of  a  severe 
burn  is  the  chief  factor  in  the  production  of  death.  According 
to  their  degree,  they  are  classified  as  burns  of  the  first,  second, 
or  third  degree. 

1.  First  degree— simple  redness  or  inflammation  of  skin. 

2.  Second  degree — inflammation,  accompanied  by  the  forma- 
tion of  blebs  or  vesicles. 

3.  Third  degree — charring  and  destruction  of  the  skin  and 
deeper  tissues. 

The  treatment  of  burns  differs  according  to  the  degree. 
For  burns  of  the  first  and  second .  degree  the  treatment  is  very 
much  the  same,  but  third  degree  burns  should  always  be  treated 
by  the  physician,  as  it  is  often  necessary  to  trim  out  charred 
tissue  and  later  to  remove  sloughing  portions.  In  the  case  of 
the  burns  in  the  first  degree,  almost  anything  that  produces  an 
impervious  covering  of  the  surface,  is  sufficient.  This  prevents 
the  entrance  of  air,  and  so  aids  in  relieving  the  pain.  It  is 
hardly  advisable  to  immerse  the  part  in  cold  water  even  tho 
this  does  afford  immediate  relief,  as  pain  is  usually  intensified 
on  removal  and  lasts  longer  than  if  it  had  been  immersed  in  hot 
water  or  some  other  application  made.  Vaseline,  carron  oil,  and 
ointment,  usually  afford  relief;  also  the  application  of  bicarbon- 
ate of  soda  or  flour;  picric  acid  may  also  be  used.  In  the  burn 
of  the  second  degree  and  in  extensive  burns  of  the  first  degree, 
the  following  is  the  plan  now  employed  by  the  majority  of  phy- 
sicians: 

First  fan  the  part  until  the  serum  has  dried  on  the  surface. 
Blebs  should  be  punctured  at  their  dependant  edges  with  a 


BURNS  95 

sterile  needle,  the  raised  epidermis  beino:  allowed  to  fall  back 
and  dry  on  the  skin.  Next  apply,  by  means  of  cotton  or  gauze, 
a  saturate  aqueous  solution  of  picric  acid.  This  should  be  ap- 
plied so  as  to  cover  the  entire  surface,  and  the  part  again  be 
fanned  or  otherwise  dried.  Next  cover  by  very  light  dusting 
with  stearate  of  zinc.  This  should  be  very  lightly  done  so  as 
not  to  leave  an  amount  which  will  favor  the  formation  of  cakes 
or  crusts.  In  case  the  area  involved  is  small,  it  will  do  no  harm 
to  apply  a  saturate  solution  of  picric  acid  in  50—70  %  alcohol. 
But  the  alcoholic  solution  should  never  be  applied  to  an  exten- 
sive area,  as  it  may  be  absorbed  and  cause  poisoning.  However, 
the  aqueous  solution  almost  never  produces  any  harmful  results, 
even  tho  applied  where  the  epidermis  has  been  entirely  removed. 

This  so-called  dry  method  of  treating  burns  is  to  be  most 
highly  recommended.  Successive  dressings  are  carried  out  in 
the  same  manner.  The  chief  item  to  be  observed  is  the  keep- 
ing of  the  surface  perfectly  dry.  This  in  itself  favors  the 
growth  of  epithelium,  and  the  picric  acid  also  stimulates  the 
formation  of  epithelium  This  general  plan  should  be  digressed 
from  only  in  case  of  infection.  If  pus  forms  on  the  surface  it 
is  necessary  to  apply  a  compress  wet  in  a  very  weak  solution  of 
some  antiseptic  for  a  few  hours  or  a  day  or  so.  It  is  then  us- 
ually best  to  return  to  the  dry  dressings.  Where  it  is  necessary 
to  follow  other  methods  of  procedure,  the  directions  of  the  phy- 
sician should  be  very  carefully  followed  in  case  the  dressings 
are  left  to  the  care  of  the  nurse.  Burns  of  the  third  degree 
should  be  under  the  constant  supervision  of  the  physician.  In 
many  cases,  however,  the  same  general  plan  may  be  followed 
as  for  burns  of  the  second  degree. 

General  items.  If  clothing  sticks  to  a  burn,  do  not  pull  it 
off,  taking  a  part  of  the  skin  surface  with  it;  but  loosen  it  by 
moistening  with  salt  solution.  Use  a  dressing  that  will  exclude 
the  air  and  prevent  friction.  Do  not  use  a  dressing  that  will 
stick  in  cakes  as  flour  and  cotton  batting. 

When  the  clothes  are  on  fire,  the  wearer  must  not  run 
about  as  this  fans  the  flames.  Have  him  lie  on  the  floor  and 
wrap  in  blankets,  rugs,  or  anything  that  will  smother  the 
flames.  In  burns  of  the  fingers,  bandage  each  separately,  as 
otherwise  they  may  grow  together. 


96  SURGICAL  NURSING 

Boils,   Ulcers,  and  Abscesses 

BOILS 

A  boil  is  a  subcutaneous  abscess  having  one  sinus,  or  open- 
ing. 

1.  Cause.     Infection. 

2.  Symptoms.     Redness,  pain,  swelling  and  local  pointing. 

3.  Treatment,— 

a.  Cold  applications  to  abort. 

b.  Hot  applications  to  hasten. 

c.  Wash  with  mild  disinfectant. 

d.  Open.     Generally  the  open  cavity  is  swabbed  with  carbolic 
and  then  with  alcohol.     If  large,  a  small  piece  of  1/4-inch  iodo- 
form  or  sterile  packing  is  put  in  to  insure  good  drainage.     Over 
this  apply  sterile  gauze  and  then  bandage  or  fasten  on  with  ad- 
hesive strips.     Before  each  dressing  irrigate  cavity  with  a  dis- 
infectant.    Adhesive  strips  are  easily  removed  by   saturating 
with  alcohol,  benzine  or  gasoline. 

e.  Avoid  pressing  or  bruising  tissue. 

CARBUNCLE 

A  carbuncle  is  a  subcutaneous  abscess  with  two  or  more  open- 
ings. It  is  practically  an  extended  boil.  Symptoms  and  treat- 
ment are  the  same  as  for  boils. 

ULCER 

An  ulcer  is  an  open  sore  on  the  surface  of  the  body  or  a 
mucous  membrane.  The  treatment  consists  first  in  cleansing 
the  surface  by  means  of  peroxide  of  hydrogen.  If  there  is  much 
pus  or  secretion,  that  must  be  removed.  It  should  then  be 
dried  and  treated  with  picric  acid  or  some  antiseptic  powder. 
Over  this  the  usual  sterile  dressing  and  bandage  are  applied. 
The  special  advantage  in  varicose  and  other  chronic  ulcers  is 
the  alternate  application  of  hot  and  cold,  carried  out  in  much 
the  same  manner  as  recommended  for  infected  wounds,  altho 
in  the  case  of  varicose  ulcers  the  alternate  hot  and  cold  spray 
is  especially  good,  and  often  massage  may  be  used  in  treating 
the  tissues  about  the  ulcer. 

ABSCESSES 

An  abscess  is  a  localized  collection  of  pus  in  some  part  of 
the  body.  It  is  indicated  by  pain  and  rise  of  temperature, 


BOILS,  ULCERS,  ABSCESSES  97 

swelling,  local  tenderness,  and  at  its  onset,  often  by  chills.  An 
abscess  is  always  to  be  treated  by  a  physician,  where  one  is 
accessible.  After  it  has  been  opened  and  surgically  cared  for, 
the  dressings  are  much  the  same  as  in  the  treatment  of  boils  or 
ulcers.  In  many  cases,  however,  surgeons  desire  to  irrigate 
abscess  cavities.  The  antiseptic  solution  used  should  be  very 
weak,  so  as  to  give  rise  to  no  danger  from  the  absorption  of 
chemicals.  The  general  condition  of  the  patient  should  be 
looked  after  by  means  of  simple  diet,  tonic  hydrotherapy,  fresh 
air,  attention  of  the  bowels,  etc. 

HEMORRHAGES 

Hemorrhage  from  veins  is  generally  slow  and  steady,  and 
the  blood  dark  red.  To  stop  hemorrhage,  exert  firm  continu- 
ous pressure  both  above  and  below  the  wound.  In  arterial 
hemorrhage  the  blood  is  bright  red  and  comes  in  spurts.  Pres- 
sure should  be  exerted  over  the  artery  between  the  cut  and  the 
heart.  Capillary  hemorrhage  is  always  present  in  evei  y  cut. 
The  color  of  the  blood  is  bright  red,  the  flow  is  slow  and  scanty. 

1.  Finger  or  toe.     Grasp   the  part  tightly   between   your 
thumb   and  finger,  making  firm  pressure  against  the  bone  at 
the  sides. 

2.  Arm  or  leg.     Place  a  small  pad  over  the  bleeding  artery; 
by  means  of  a  handkerchief  or  firm  strip  of  cloth,  tie  a  bandage 
about  the  limb,   drawing  it  tighter  by  inserting  a  stick  and 
twisting  the  bandage. 

To  stop  a  hemorrhage  from  the  brachial  artery,  make  firm 
pressure  over  this  artery  at  the  inner  side  of  the  biceps  muscle. 

To  compress  the  axillary  artery,  grasp  the  arm  just  below 
the  shoulder  with  both  hands.  With  the  fingers  in  the  axilla, 
press  firmly  against  the  upper  end  of  the  humerus. 

To  stop  hemorrhage  from  a  large  artery  in  the  leg,  make 
firm  pressure  in  the  center  of  the  popliteal  space. 

To  compress  the  femoral  artery,  exert  pressure  just  below 
Pouparts  ligament,  1/3  of  the  distance  from  the  pubes  to  the 
spine  of  the  ilium. 

3.  Neck.     In  arterial  hemorrhage  about  the   neck,    make 
deep  pressure  at  the  side  of  the  middle  line  just  above  the  collar 

7 


98  SURGICAL  NURSING 

bone.     This  will  press  the  carotid  artery  back  against  the  spinal 
column. 

4.  Face.  Exert  direct  pressure  over  the  wound  or  press  the 
facial  artery  against  the  lower  jaw  bone.  It  will  be  found  just 
in  front  of  the  angle  of  the  jaw.  For  scalp  wound,  apply  ice  or 
very  hot  water  directly  to  the  wound  itself. 

EPISTAXIS 

Snuff  very  cold  water,  salt  and  water,  or  a  solution  of  alum 
(dessert  spoonful  to  the  half  pint  of  hot  water).  Hold  the 
arms  up  over  the  head,  apply  ice  to  the  back  of  the  neck  and 
over  the  nose,  and  have  the  patient  hold  his  hands  in  cold  water 
or  on  a  piece  of  ice.  Where  hemorrhage  does  not  respond  to 
other  measures,  it  may  be  necessary  to  plug  the  anterior  and 
posterior  nares  with  cotton.  This  requires  special  skill,  and  is  us- 
ually to  be  carried  out  by  a  physician. 

HEMORRHAGE  AFTER  TOOTH  EXTRACTION 

Plug  the  cavity  with  small  pledget  of  cotton  dipped  in  ad- 
renalin solution,  a  solution  of  alum,  or  vinegar. 

HEMATEMESIS 

In  hemorrhage  from  the  stomach,  blood  is  usually  dark  and 
has  the  appearance  of  coffee  grounds.  If  the  hemorrhage  is 
very  profuse  and  the  vomiting  immediate,  the  blood  may  be 
bright  red.  The  cause  is  usually  cancer  or  ulcer  of  the  stomach. 

Treatment,  — 

1.  Keep  quiet  in  recumbent  position. 

2.  Ice  bag  over  the  stomach. 

3.  May  swallow  bits  of  ice. 

4.  Heat  to  feet. 

5.  Notify  physician. 

HEMOPTYSIS 

In  hemorrhage  from  the  lungs  the  blood  is  bright  red  in 
color  and  frothy.  The  most  common  cause  is  tuberculosis. 
Other  causes  are  strain,  lifting,  congestion  of  the  lung. 


SPRAINS  AND  FRACTURES  99 

DIFFERENCES  IN~ 
HEMOPTYSIS  HEMATEMESIS 

1.  Pain  in  chest.  1.  Tenderness  over  stomach. 

2.  Blood  frothy,  alkaline.  2.  Not  frothy,  acid. 

3.  Bright  red.  3.  Dark  red. 

4.  Mixed  with  phlegm.  4.  Mixed  with  food. 

5.  Coughed  up.  5.  Vomited  up. 

6.  Difficult  breathing.  6.  Nausea. 

HEMORRHAGE  FROM  THE  BOWELS 

Hemorrhage  from  the  bowels  may  be  caused  by  hemor- 
rho'ds,  typhoid  fever,  tuberculosis,  cancer,  ulcer,  and  many 
other  conditions.  In  hemorrhage  from  the  upper  bowel  the 
blood  is  usually  dark  and  mixed  with  feces.  In  hemorrhages 
from  the  rectum,  the  blood  will  be  passed  by  itself  or  may  coat 
the  feces. 

Treatment,— 

1.  Cold  to  abdomen. 

2.  Heat  to  limbs. 

3.  Quiet  and  absolute  rest. 

4.  Notify  the  physician. 

SPRAINS 

A  sprain  is  due  to  the  tearing  or  rupture  of  ligaments.  It 
is  most  frequently  in  the  ankles.  As  far  as  possible  the  part 
should  be  kept  at  rest  for  a  few  days.  The  alternate  hot  and 
cold  foot  bath  is  an  excellent  means  of  preventing  undue  swell- 
ing and  of  relieving  the  pain.  The  flowing  cold  foot  bath  may 
be  used.  Continuous  heat,  such  as  the  hot  foot  bath  or  fomen- 
tation, is  usually  never  as  efficient  as  the  measures  just  recom- 
mended. Bandaging  the  part  only  prevents  swelling  without 
in  any  wise  overcoming  the  cause  of  the  swelling. 

FRACTURES 

Fracture  is  the  breaking  of  a  bone.  The  following  varieties 
are  distinguished:  Simple,  comminuted,  green  stick,  and  com- 
pound or  open  fracture. 

Comminuted  fracture  is  one  in  which  the  bone  is  splintered, 
several  small  pieces  being  formed. 


100  SURGICAL  NURSING 

Green  stick  fracture  usually  occurs  in  the  bones  of  children. 
It  is  a  partial  break,  usually  without  displacement, —  in  much 
the  same  way  as  a  green  stick  breaks  when  bent. 

Compound  or  open  fracture  is  one  in  which  there  is  an  open- 
ing from  the  skin  or  the  mucous  membrane  down  to  the  seat 
of  fracture.  Because  of  the  opportunity  for  the  entrance  of 
germs,  infection  is  very  likely  to  take  place. 

Treatment,  — 

In  the  case  of  fracture,  that  which  frequently  devolves  up- 
on a  nurse  is  treatment  to  relieve  the  pain  while  awaiting  for 
the  arrival  of  the  physician.  The  relief  of  the  pain  and  the  re- 
laxation of  the  muscles  is  best  accomplished  by  the  use  of  the 
fomentation.  This  should  be  applied  as  hot  as  can  be  borne, 
care  being  taken  that  a  burn  is  not  produced. 

In  case  of  compound  fracture,  the  break  in  the  skin 
should  be  thoroly  cleaned  and  any  dirt  or  foreign  matter  picked 
out.  If  the  ends  of  the  bone  protrude,  it  is  well  to  leave  them 
until  the  physician  arrives,  at  least  they  should  not  be  replaced 
until  the  parts  have  been  thoroly  disinfected. 


PART  III 
SOLUTIONS 

CHEMICALS  IN  COMMON  USE 

Corrosive  Sublimate  (HgCl2) 

1.  Properties.     Strength  of  saturation:  1  part  of  bichloride 
made  up  with  cold  water  16  parts.     An  equal  amount  of  com- 
mon salt  added  to  the  bichloride  will  hasten  its  solution.     The 
addition  of  HC1  or  citric  acid  aids  its  disinfectant  action. 

Bichloride  corrodes  instruments.  It  is  not  a  good  disin- 
fectant for  clothing  as  it  stains  white  materials  yellow. 

It  is  decomposed  by  alkalies  and  is  precipitated  by  albumen. 

2.  Solutions.     Solutions  of  this  drug  varying  from  1 — 500 
to  1—10,000  are  used.     Those  most  often  employed  are  1—500, 
1-1000,  and  1—2000. 

The  weaker  solutions  are  used  for  irrigating  cavities.  As 
an  absolute  disinfectant,  solutions  weaker  than  1—1000  should 
not  be  used. 

It  is  not  an  efficacious  disinfectant  for  stools,  bloody  or  pur- 
ulent discharges  as  it  hardens  albumen,  forming  a  coat  or  shell 
within  which  germs  retain  their  vitality. 

Carbolic  Acid  (C6H5OH) 

1.  Properties.     Strength  of  saturation:  1  part  of  acid  to  15 
parts  water.     However,  the  standard  solution  for  ward  use  is 
made  with  20  parts  of  water. 

It  is  a  product  derived  from  coal  tar  by  distillation.  Chem- 
ically it  is  not  an  acid  but  a  phenol.  The  pure  acid  is  colorless. 
If  5%  water  is  added  to  the  melted  crystals,  the  solution  will 
not  re-crystallize.  Carbolic  acid  is  freely  soluble  in  glycerine, 
alcohol,  and  ether. 

2.  Solutions.     All  solutions  are  preferably  made  with  hot 
water  to  insure  the  thoro  dissolving  of  the  globules,  as  these 


SOLUTIONS 

are  very  corrosive.  The  solutions  in  common  use  are  1-20  (5% ) , 
and  1 — 40  (2  1/2%).  Solutions  weaker  than  5%  will  not  destroy 
all  germs,  but  because  of  its  irritating  qualities  it  can  not  always 
be  used  that  strong. 

It  does  not  discolor  instruments  or  clothing.  Long  contin- 
ued submersion  in  the  pure  acid  will  deprive,  knives  and  scis- 
sors of  their  temper  and  edge.  Five  minutes  in  the  pure  acid 
is  sufficient  to  insure  thoro  disinfection.  Clothing  should  stand 
at  least  1  hour  in  a  5%  solution. 

The  odor  of  carbolic  may  be  covered  by  using  oil  of  pepper- 
mint or  cinnamon. 

Lysol 

1.  Properties.     Full  strength  or  (100%)    solution.     It  is  a 
coal  tar  product,  brown,  oily,  saponified  liquid,  containing  about 
50  of  cresols.     It  is  less  poisonous  than  carbolic  acid. 

2.  Solutions.     Solutions  are  used  from  1 — 5%.     Those  in 
most  common  use  range  from  1/2% — 2%.     It  may  be  used  for 
the  disinfection  of  anything  in  the  sick  room  except  rubber 
goods  that  must  stand  in  the  solution  a  long  time,  as  it  softens 
the  rubber. 

Creolin 

1.  Properties.     Full   strength   (100%)   solution.     A  black, 
syrupy  liquid.    When  mixed  with  water  forms  an  opaque  emul- 
sion, which  is  a  disadvantage  in  the  disinfection  of  instruments, 
since  they  can  not  easily  be  found  in  it. 

It  is  not  so  poisonous  as  carbolic  acid. 

2.  Solutions.     1%— 5%   are  used.     For  cleansing  hands  a 
5%  solution  is  generally  used.     For  vaginal  irrigation  a  1%  so- 
lution is  used. 

Formaldehyde  (CH2O) 

1.  Properties.  A  colorless  gas  with  a  strong,  pungent  ir- 
ritating odor.  It  is  very  irritating  to  the  mucous  membranes 
and  skin.  Readily  soluble  in  water.  Formalin  is  an  aqueous 
solution  containing  about  40%  of  the  gas.  It  is  a  good  deodor- 
izer. Used  very  extensively  for  the  fumigation  of  rooms.  Am- 
monia will  destroy  the  odor.  Its  antiseptic  properties  are  con- 
sidered superior  to  bichloride  of  mercury.  It  does  not  corrode 
or  tarnish  metal  or  injure  fabrics. 


COMMON   CHEMICALS  103 

2.  Solutions.  All  aqueous  solutions  are  made  from  for- 
malin. Cold  water  should  be  used,  as  heat  evolves  gas,  weak- 
ening the  solution. 

For  the  disinfection  of  colon  tubes  or  lavage  tubes,  use  a 
1%  solution  and  allow  to  stand  at  least  one-half  hour. 

For  rubber  irrigating  points  or  articles  to  be  used  in  an 
operating  room,  a  5%  solution  should  be  used  and  the  immersion 
continued  for  about  one  hour. 

Potassium  Permanganate 

1.  Properties.     Strength  of  saturation,  1 — 16.    The  crystals 
are  dark  purple,  slender  prisms,  inodorous.    Solutions  not  made 
with  distilled  water  are  likely  to  deteriorate,    especially  if  ex- 
posed to  the  light. 

2.  Solutions.     It  is  used  in  varying  strengths  from  1 — 16  to 
1—5000. 

For  hands,  use  a  saturated  solution.  In  weaker  solutions  it 
is  used  on  wounds,  especially  those  having  an  offensive  dis- 
charge. A.  1 — 1000  solution  may  be  used  for  gargles,  douches  or 
sprays. 

It  is  not  useful  in  disinfecting  excreta,  as  the  amount  re- 
quired to  make  it  effectual  would  be  a  great  expense. 

Boracic  Acid  (H3BO3) 

1.  Properties.     Strength  of  saturation,  about  1—25.     The 
crystals  are  pearly  white  and  glistening,  and  non-irritating. 

2.  Solutions.    It  is  much  used  in  ophthalmic  and  aural  prac- 
tice, also  for  superficial  wounds  and  bladder  irrigation.     As  a 
wash  for  the  eyes,  a  2%  solution  is  commonly  used. 

Oxalic  Acid  (C2H2O4,  2H2O) 

1.  Properties.     Strength  of  saturation,   about  1 — 10.     The 
crystals  are  colorless  and  four  sided.     They  closely  resemble  in 
appearance  those  of  magnesium  sulphate  and  zinc  sulphate.     It 
is  a  powerful  germicide,   and  very  irritating.     It  removes  the 
stain  of  potassium  permanganate. 

2.  Solutions.     The  saturate  solution  is  used  for  hand  disin- 
fection.    Oxalic  acid  is  never  used  for  irrigating  cavities,  as  it 
is  highly  toxic. 

Salt  (NaCl) 

1.  Properties.    Strength  of  saturation,  1—2  1/2.    Exists  in 


104  SOLUTIONS 

the  blood  in  the  strength  of  6/10%.  Water  alone  is  an  irritant 
to  abraded  tissue,  but  a  weak  solution  of  salt  makes  it  non- 
irritant. 

2.  Solutions.  The  solution  most  commonly  used  is  the  nor- 
mal or  physiologic  saline  solution.  It  is  so-called  because  it  ap- 
proximates the  density  of  blood  serum.  To  make  this,  use  one 
of  the  following  formulae:— 

(a)  6  grams  of  salt  to  1000  c.c.  of  water,  (b)  1  tsp.  of  salt 
1  pt.  of  water,  (c)  15  c.c.  saturated  solution  to  1000  c.c.  of 
water. 

Alum  (KA1  (SO4)2. 12H2O) 

1.  Properties.    Strength  of  saturation,  1 — 9.    It  is  an  astrin- 
gent and  styptic. 

2.  Solutions.    The  saturated  solution  is  often  used  to  arrest 
uterine  hemorrhage  or  profuse  flowing  by  giving  a  vaginal  irri- 
gation at  a  temperature  of  120°  F. 

Alcohol  (C2H5OH) 

1.  Properties.     A  colorless,  volatile  liquid  of  an  agreeable 
odor  and  burning  taste.     It  is  a  solvent  for  many  substances. 
Mixes  with  water  in  all  proportions. 

2.  Solutions.     Grain  alcohol,  95  %;  proof  spirit,  50%. 

Peroxide  of  Hydrogen  (H2O2) 

1.  Properties.     Slightly  acid,  watery  solution  of  hydrogen 
dioxide,  containing  when  fresh  about  3%  the  pure  dioxide,  cor- 
responding to  about  10  volumes  of  oxygen.     It  is  an  antiseptic, 
deodorant  and  styptic.     Its  value  depends  upon  the  liberation  of 
oxygen.     When  poured  into  a  wound,  effervescence  takes  place 
which   carries   off   any  tissue   shreds   that   can  not  be  easily 
reached.     It  should  not  be  relied  upon  as  a  disinfectant. 

It  must  be  kept  in  a  cool,  dark  place,  and  readily  decom- 
poses on  coming  in  contact  with  metals. 

2.  Solutions.     Used  for  (1)  gargles,    (2)  irrigating  wounds 
or  ulcers  where  pus  is  present. 

It  is  a  direct  antagonist  of  the  tetanus  germ,  since  the 
latter  can  not  live  in  the  presence  of  oxygen. 

Sodium  Bicarbonate  (NaHCO3) 

1.  Properties.  Strength  of  saturation,  1—12.  It  is  com- 
monly called  baking  soda. 


COMMON  CHEMICALS  105 

2.  Solutions.  A  1%  solution  is  used  in  which  to  boil  in- 
struments. 

Sodium  Carbonate  (Na2CO3) 

1.  Properties.  Strength  of  saturation,  1 — 2.  Transparent, 
colorless  crystals,  which  break  down  into  a  white  powder  on 
standing  (effloresce).  This  chemical  is  commonly  called  sal 
soda,  or  washing  soda.  It  will  remove  the  stains  made  by  bi- 
chloride of  mercury  on  china  or  glass. 

Chlorinated  Lime  (Chloride  of  Lime) 

1.  Properties.     Made  by  the  action  of  chlorine  on  slacked 
lime.     It  contains  about  35%  of  available  chlorine.     It  should 
be  used  fresh  as  its  disinfectant  properties  are  due  to  the  action 
of  chlorine. 

2.  Solutions.     The  standard  solution  contains  6  ounces  to 
the  gallon  of  water  (4%).     It  is  a  good  disinfectant  for  feces, 
sputum,  or  urine. 

lodoform  (CHI3) 

1.  Properties.     It  has  no  decided  antiseptic  properties.     It 
is  useful  because  it  inhibits  the  growth  of  bacteria  and  thus 
prevents  decomposition.     When  applied  to  raw  surfaces  it  is 
occasionally  absorbed  into  the  system,   causing  symptoms  of 
poisoning.     Spirits  of  turpentine  will  remove  the  disagreeable 
odor  of  the  drug.     It  darkens  upon  exposure  to  a  bright  light, 
and  is  likely  to  cake  when  it  becomes  moist. 

2.  Preparations.     It  is  used  for  impregnating  gauze  dress- 
ings,  for  dusting  on  ulcers  or  wounds.     Dissolved  in  ether  or 
olive  oil  is  often  injected  into  sinuses  or  tubercular  abscesses, 
and  is  an  ingredient  of  bone  wax  used  for  filling  cavities  in  bone. 

Argyrol 

1.  Properties.     Strong,  non-irritating  and  non-toxic  disin- 
fectant.   Stains  may  be  removed  by  immersion  in  1 — 500  HgCk 

2.  Solutions.     Better  results  will  follow  the  use  of  freshly 
prepared  solutions.     In  cystitis,   or  an  irritable  bladder,   one 
ounce  of  10—25%  is  injected  and  allowed  to  remain  in  the  blad- 
der.    It  is  used  in  ophthalmic  surgery  quite  extensively.    Is  also 
palliative  or  curative  in  many  diseases  of  the  rectum. 


THE  METRIC  SYSTEM 

The  metric  system  is  employed  almost  universally  in 
Europe,  and  it  is  being  rapidly  adopted  in  America.  Because 
of  its  simplicity,  it  greatly  facilitates  the  calculations  incident 
to  the  making  up  of  solutions.  The  unit  of  length  is  called  the 
meter —  (39. 37  in. ) .  The  Subdivisions  of  the  meter  are  expressed 
by  Latin  prefixes  while  the  multiples  are  designated  by  Greek 
prefixes.  The  two  arrangements  are  as  follows:— 

DECREASING  SCALE 

Meter. 

Decimeter — one-tenth  (1/10)  of  a  meter. 
Centimeter— one-hundredth  (1/100)  of  a  meter. 
Millimeter — one  thousandth  (1/1000)  of  a  meter. 

INCREASING  SCALE 

Meter. 

Decameter — ten  meters. 

Hectometer — hundred  meters. 

Kilo  meter — one  thousand  meters. 

The  cube  of  a  centimeter  is  called  a  cubic  centimeter  (c.c. ). 

The  unit  of  capacity  is  called  a  liter,  and  is  equivalent  to 
1000  c.c. 

The  unit  of  weight  is  called  a  gram,  and  is  equivalent  to 
the  weight  of  1  c.c.  of  distilled  water  at  4°  C. 

The  same  prefixes  used  for  the  meter  are  used  for  the  liter 
and  gram  to  denote  their  division  and  multiplication.  However, 
in  the  case  of  the  liter  the  divisions  are  rarely  spoken  of  as  deci- 
liter, centiliter,  etc.,  but  are  generally  designated  100  c.c.  in- 
stead of  deciliter,  10  c.c.  instead  of  centiliter,  etc. 

APPROXIMATE   EQUIVALENTS 

1  meter 39.37  in. 

25  millimeters  (mm)      1       in. 

1  liter 33.81  fluid  ounces  or  about  2  pts. 

30c.c.  1        fluid  ounce. 

4  c.c. 1        dram. 

5  c.  c.  1        teaspoonf ul. 

1  c.m.   .  2/5  in. 

1  gram___  15  1/2  gr. 

1  grain  _  .065  gm. 

1  kilometer  _  3/5  mile. 

1  kilogram 21/5  pounds,  avoirdupois. 

The  United  States  nickel  (five  cent  piece)  weighs  5  grams, 
and  is  2  centimeters  in  diameter. 


PREPARATION  OF  SOLUTIONS 

LESSON  I. 

Coal  Tar  Products 

Full  strength  (100%)  chemicals:  lysol,  carbolic,  creolin, 
creosope. 

Carbolic  acid  in  liquid  form  is  95%  but  is  always  used  as 
tho  it  were  100%,  as  the  difference  is  so  slight.  In  making  up 
full  strength  solutions,  it  is  a  good  plan  to  use  a  liter  (1000  c.c.) 
as  a  starting  point.  Since  1%  of  1000  c.c.  is  10  c.c.,  from  this 
any  quantity  and  any  per  cent  can  readily  be  estimated. 

Problems 

One.     Make  up  1  liter  of  2%  lysol. 
1  liter=1000  c.c. 

1%      =1/100  of  1000  c.c.  or  10  c.c. 
2%      =2X10  c.c.  or  20  c.c  ,  the  amount  of  lysol 
it  takes  to  make  1  liter  of  2  %  solution. 

Two.  How  many  c.c.  of  creolin  does  it  take  to  make  a 
liter  of  1/2%  solution? 

1  liter=1000  c.c. 

1%      =1/100  of  1000  c.c.  or  10  c.c. 
1/2%      =10  c.c. -^2,  or  5  c.c.,  the  required  amount. 

Three.     Disinfect  2  liters  of  sick  room  discharges  with  car- 
bolic acid,  using  sufficient  to  make  a  5%  solution. 
1%      of  1000  c.c.  (1  liter)  =10  c.c. 
5%  =5X10  or  50  c.c.,   the  amount  of  carbolic  it 
would  take  to  make  1  liter  of  a  5%  solution. 

To  make  2  liters  it  would  take  2X50  c.c.  or  100  c.c.  (3  1/3 
oz. )  of  carbolic  acid. 

Four.     Make  up  1  pt.  of  2%  lysol. 
1  liter=1000  c.c. 
1%  of  1000  c.c.  =10  c.c. 

2%  =2X10  or  20  c.c.,  the  amount  of  lysol  to  make 
1  liter  of  27c  solution. 

A  pint=l/2  liter,  thus  20  c.c.  -^-2=10  c.c.  (5  iiss)  the  amount 
of  lysol  required  to  make  1  pint  of  solution.  . 


108  SOLUTIONS 

LESSON  II. 

Formaldehyde  Solutions 

All  formaldehyde  solutions  are  made  from  formalin  which 
is  40%  formaldehyde. 

1%  =1/100  or  in  100  parts,  1  part  is  the  chemical. 

2%  =2/100  (1/50)  or  in  100  parts,  2  parts  are  the  chemical. 

There  is  one  part  of  the  chemical  to  every  50  of  water. 

4%  =4/100  (1/25)  or  in  100  parts  4  parts  are  of  the  chem- 
ical. Thus  in  every  25  parts  of  water  there  is  one  of  the  chem- 
ical, making  a  solution  of  1 — 25  which  is  equivalent  to  4%. 

5%  =5/100  or  1— 20. 

6%  =6/100  or  1—162/3. 
10%  =10/100  or  1—10. 
40%=40/100  or  1—2  1/2. 
50%  =50/100  or  1—2. 

Thus  we  see  that  formalin  (40%)  is  a  1—21/2  solution. 
It  takes  21/2  c.c.  of  the  solution  to  contain  1  c.c.  of  the  chem- 
ical. Thus  in  making  up  solutions  from  formalin  it  takes  21/2 
times  as  much  as  it  would  to  make  up  a  solution  from  a  chemical 
that  is  full  strength. 

Problems 
One.     Make  up  1  liter  of  1%  formaldehyde. 

1%  of  1000  c.c.  =10  c.c.,  full  strength. 

10  c.c.  X2  1/2=25  c.c.,  the  quantity  of  formalin  it 
requires  to  make  a  liter  of  a  1%  solution,  thus  we  deduce  the 
following  rule:— 

'To  make  up  solutions  from  formalin,  proceed  just  as  in 
full  strength  solutions,  multiplying  the  results  by  2  1/2. " 

Two.    How  much  formalin  will  it  take  to  make  2  liters  of 

1/2%  solution? 

1  liter=1000  c.c. 

1%       =1/100  of  1000  c.c.  or  10  c.c. 
1/2%       =10  c.c. ^2,  or  5  c.c.  for  1  liter. 
2  Iiters=2x5  c.c.,  or  10  c.c.  of  full  strength. 
10  c.c.  X2  1/2=25  c.c.,  the  amount  of  formalin  re- 
quired to  make  2  liters  of  1/2%  solution. 


PREPARATION  OF  SOLUTIONS  109 

LESSON  III. 

Bichloride  of  Mercury    (HgCl2) 

Solutions  of  bichloride  of  mercury  may  be  made  up  from 
the  following:— 

1.  Tablets. 

2.  Saturated  solution. 

3.  Stock  solutions. 

4.  Crystals. 

The  nurse  should  familiarize  herself  with  every  form  of  a 
chemical  and  in  making  up  solutions  she  should  be  able  to  utilize 
whichever  form  may  be  at  hand.  Each  of  the  above  will  be 
considered  separately. 

No.  /.,   Tablets 

The  two  most  common  forms  of  tablets  are  those  containing 
7.3  gr.  and  those  containing  1.8  gr. 

7.3  gr.  (1/2  gm.  approx. )  to  aqua  1/2  liter  (1  pt.)  =1-1000 
HgCb  4  of  the  small  tablets  are  equivalent  to  one  of  the  large 
ones  containing  (7.3  gr.).  The  advantage  of  the  smaller  tablets 
can  readily  be  seen  in  the  making  of  weak  solutions,  as  other- 
wise the  large  tablets  would  have  to  be  divided  (this  is  in- 
accurate) or  else  there  will  be  quite  a  waste. 

1  tab.  (7.3    gr.  or  1/2  gm.)  to  aq.  1/2  liter  or  1  pt  —1—1000. 

2  "    (14.6  "    "1         "    )  "    "      1       "      "  2  "•  -1—1000. 
1    "  (7.3     "    "  1/2     "    )  "    "      1       "      "  2  "  —1—2000. 

1/2  "      2sm.  tab.  "    "      1       "      "  2  "  -1—4000. 

Problems 

One.  Make  up  5  liters  of  1-1000  HgCl2,  using  the  large 
tablets. 

1  tab.  to  1/2  liter— 1-1000. 

2  tab.  to  1  liter     -1-1000. 

5  liters— 2  tab.  X5  or  10  tablets,  the  number  of 
tablets  required. 

Two.     Make  up  2  liters  of  1—4000  using  the  small  tablets. 
4  sm.  tablets  to  1/2  liter— 1-1000. 
2    "  <4    1       "    -1—4000. 

2  tab.  X2— 4  sm.  tab.,  the  number  required  for  2 
liters  of  1-1000. 


110  SOLUTIONS 

Three.    Make  up  3  liters  of  1—500  from  the  large  tablets. 
To  make  1  liter    of  1—1000=2  large  tablets. 
To  make  1  liter    of  1-500  =4  large  tablets. 
To  make  3  liters  of  1-500  -=4X3  or  12  tablets. 

LESSON  IV. 

Bichloride  of  Mercury 

No.  II.,  Saturated  Solution 

Bichloride  of  mercury  saturates  at  1—16.  By  this  we  mean 
that  every  16  c.c.  of  water  contains  1  gm.  of  the  chemical. 

In  making  up  solutions  from  the  saturated  solution  always 
find  first  of  all  how  many  grams  of  the  chemical  will  be  needed, 
then  if  16  c.c.  of  the  sat.  sol.  is  equivalent  to  1  gm.,  the  amount 
needed  can  easily  be  calculated  and  measured. 

Problems 

One.  Make  up  2  liters  of  1-1000  HgCl2  from  the  saturated 
solution. 

To  make  1  liter  of  1—1000  requires  1  gm.  of  the  chemical 
and  to  make  2  liters,  2  gms.  would  be  necessary. 

If  1  gm.  of  the  chemical  is  equivalent  to  16  c.c.  of  the  sat. 
sol.,  2  gms.  would  equal  32  c.c.,  or  5j,  the  amount  of  sat.  sol. 
required. 

Two.     Make  up  3  liters  of  1—4000  from  the  sat.  sol. 
To  make  1  liter  of  1—1000=1  gm. 
"       "     1     "     "  1-4000=1/4  gm. 
"       "     3     "     "  1-4000=3/4  gm. 
3/4  of  16  c.c.  =12  c.c.  (5iii)  of  sat.  sol. 

LESSON  V. 

Bichloride  of  Mercury 

No.  III. ,  Stock  Solutions 

A  stock  solution  is  a  solution  of  a  certain  per  cent  that  is 
always  kept  on  hand  to  be  used  in  making  up  weaker  solutions. 
The  most  common  stock  solutions  are  1—20  and  1  —  40. 

A  1—20  solution  signifies  that  every  20  c.c.  of  the  solution 
contain  1  gm.  of  the  chemical.  The  same  method  is  used  in 
making  up  solutions  from  stock  solutions  that  is  observed  in 
using  the  saturated  solution. 


PREPARA  TION  OF  SOL  UTIONS  111 

Problems 

One.  Make  up  2  liters  of  1—3000  HgCh  from  the  stock 
solution  1—20. 

1  liter  of  1-1000  takes  1  gm. 
1     "     "  1—3000     "     1/3  gm. 

3  "  1-  300     "    3X1/3  or  1  gm. 

Since  1  gm.  is  equivalent  to  200  c.c.  of  the  stock  solution, 
just  20  c.c.  will  be  needed. 

Two.   Make  up  4  liters  of  1—2000  from  the  stock  sol.  (1—40) . 
1  liter  of  1 — 1000  takes  1  gm.  of  crystals. 
1     "     "  1-2000      "   1/2  "    " 

4  "     "1-2000       "    4Xl/2or2gms. 

1  gm.=40  c.c.  of  stock  sol. 

2  "    =2X40  or  80  c.c.  stock  sol. 

No.  IV.,  Crystals 

In  using  the  crystals  to  make  up  solutions  it  is  necessary  to 
weigh  them.  This  is  often  inconvenient,  so  when  the 
nurse  is  given  crystals  she  generally  makes  up  a  sat.  sol.  and 
uses  that.  However,  a  few  problems  will  be  given  to  demon- 
strate the  method  of  calculating  the  amount  of  crystals  needed. 

Problems 

One.     Make  up  6  liters  of  1-500. 

To  make  up  1  liter  of  1-1000=1  gm. 
"  1  "  "  1-  500=2  gm. 
"  6  "  "  1-  500=6  X  2  or  12  gm. 

As  the  nurse  very  seldom  has  access  to  the  metric  scales, 
it  is  necessary  to  convert  the  amount  needed  into  the  avoirdupois 
equivalent,  hence, 

1  gm.— 15  1/2  gr. 

12  gm.— 151/2  gr.  X12  or  186  gr.  (approx.  5iij  as  there 
are  60  gr.  to  5j.) 

Two.     Make  up  3  liters  of  1—5000  HgCk 
1  liter  of  1—1000=1  gm. 
1     "     "  1-5000=1/5  gm. 

3  "     "  1—5000=3/5  gm. 

3/5  of  15  1/2  gr.=9  gr.  (approximately). 


112  SOLUTIONS 

LESSON  VI. 

Potassium  Permanganate  (KMnO4) 

As  the  strength  of  saturation  of  potassium  permanganate 
is  the  same  as  bichloride  of  mercury,  its  solutions  are  made  up 
in  the  same  way.  The  only  difference  being  in  the  size  of  the 
tablets.  The  tablets  of  potassium  permanganate  most  com- 
monly used  are  the  1  gr.  or  the  5  gr.  So  if  the  amount  of  the 
crystal  needed  is  estimated  in  grams,  it  can  quickly  be  con- 
verted into  grains,  and  then  the  number  of  tablets  may  be  easily 
estimated. 

Boracic  Acid  (H3BO;J) 

Strength  of  saturation— 1 — 25,  or  4%. 

Problems 

One.     Make  up  6  liters  of  3%  from  the  crystals. 
To  make  1  liter  of  1%  (1—100)  =10  gm. 
"       "      1     "     "3%         "       -3X10  or  30  gm. 
14       "      6     '*     "3%  =6X30  or  180  gm. 

30  gm.=l  ounce. 
180  gm.— 6  ounces. 

Two.     Make  up  4  liters  of  2%  from  the  sat.  sol. 
1  gm.  of  crystal — 25  c.  c.  of  sat.  sol. 
To  make  1  liter  of  1%  (1—100)  =-10  gm. 

"       "     1     "     "2%        "       -2X10  or  20  gm. 

"       "     4     "     "2%  -20X4  or  80  gm. 

25  c.c.  X  80— amount  of  sat.  sol.  or  2000  c.c.  (21.). 

Three.     Make  up  1  liter  of  1%  from  the  sat.  sol. 
To  make  1  liter  of  1%— 10  gm. 
25  c.c.  X 10— 250  c.c.  of  sat.  sol.  (1/4  liter). 

LESSON  VII. 

Salt  Solutions 

Strength  of  saturation— 1—2  1/2,  or  40%. 

The  solution  of  salt  most  commonly  used  is  the  normal 
saline  or  0.6%,  so  called  because  it  contains  the  same  amount 
of  salt  as  blood  serum. 


PREPARATION  OF  SOLUTIONS  US 

Problems 

One.     Make  up  3  liters  of  normal  saline  from  the  sat.  sol. 
To  make  1  liter  of  1—100  (1%)=10  gm. 
"      "      I     "     "  6/10%  =6/10  of  10  or  6  gm. 
Since  21/2  c.c.  of  sat.  sol.  is  equivalent  to  1  gm.,  6  gms. 
would=6x2  1/2  or  15  c.c.  of  sat.  sol.  to  1  liter. 

3  liters  would  equal  3X15  or  45  c.c.  (1  1/2  oz.). 

Two.     Make  up  4  liters  of  normal  sol.  from  the  crystal. 
1  liter =10  gm,  salt  for  a  1%. 
1     "   =6/10  of  10  gm.  salt  or  6  gm.  for  6/10%. 
6  gm.     10=24  gm.  (4/5  oz.)  amount  required. 
There  are  also  saline  tablets  of  varying  strenth  on   the 
market,  but  full  directions  for  their  use  are  always  found  on 
the  label. 

Cocain  Solutions 

In  making  up  cocain  solutions  the  use  of  the  metric  system 
is  not  practical  for  the  following  reasons:  — 

1.  Solutions  are  often  made  from  the  crystals,   which  must 
be  weighed  and  the  metric  weights  are  not  commonly  used. 

2.  The  solution  is  used  in  small  quantities  so  that  it  is  easier 
to  calculate  in  grains  than  in  grams. 

All  cocain  solutions  are  made  with  cold  water. 

Problems 

One.     Make  up  1  oz.  of  1%  cocain  from  the  crystals. 
480gr.=l  oz. 
1%  of  480=1/100  of  480  or  4.8  gr.  amount  required. 

Two.     Make  up  3  dr.  of  1/2%  cocain  from  1/2  gr.  tablets. 
480gr.=l  oz. 
60gr.=l  dr. 
180  gr.  =3  dr. 
1%  of  180  gr.  =1.8. 
1/2%  =1.8  gr.-^-2=0.9  gr. 
0.9  gr.=2  tabl.  approx. 

Three.   Make  up  2  oz.  of  1%  sol.  from  the  crystals. 
480gr.=l  oz. 
960  gr.=2oz. 


114  SOLUTIONS 

\l/c  of  960  gr.  —9.6  gr.  amount  required. 
How  to  make  cocain  solutions  from  a  4%  sol.— 
l%=l/4of  4%. 

2%  =1/2  "    " 
3%— 3/4  "    " 

Problems 

One.     Make  up  1/2  oz.  of  2%  cocain. 

1/2  of  1/2  oz.— 1/4  oz.  or  5ii.     Hence  it  would 
take  5ii  of  4%  cocain  and  5ii  of  aqua. 

Two.    Make  up  5ii  of  3'#  cocain. 
5ii^-8  c.c. 

3/4  of  8  c.c. —6  c.c.,  amount  of  4%  cocain  required. 
Add  to  this  2  c.c.  of  aqua. 

The  underlying  principles  to  be  observed  in  the  making  of 
all  solutions  may  be  briefly  summed  up  as  follows:  — 

1.  In  making  up  a  solution  from  a  chemical  in  the  liquid 
form,  first  find  how  many  c.c.  of  the  full  strength  chemical  are 
required  for  1  liter  of  1%,  and  if  that  is  understood  thoroly,  any 
strength  can  be  easily  and  accurately  computed  from  that. 

2.  In  making  up  a  solution  from  the  chemical  in  the  crys- 
talline form,  first  determine  how  many  grains  will  be  required 
to  make  1  liter  of  either  1  —  100  or  1—1000,   whichever  is  most 
convenient,  depending  largely  upon  the  chemical  used. 

3.  All  solutions  from  chemicals  in  common  use  are  made 
with  hot  water,  except  cocain  and  formaldehyde. 


INDEX 

References  are  to  the  pages. 


Abscesses,  96 

Accidents  and  minor  surgery,  90-100 

Administration  of  medicine,  35 

After-Treatment,  76-89 

Alcohol,  104 

poisoning  from,  52 
Alum,  104 
Anesthetics,  73-75 

poisoning  from,  52 
Antidotes  for  poisons,  48-54 
Antipyretics,  poisoning  from,  52 
Argyrpl,  105 
Arsenic  poisoning,  49 
Aural  douche,  24 

Beds  and  bed  making,  12-30 

Bedside  records,  7-11 

Bed  sores,  43 

Belladonna,  poisoning  from,  52 

Bichloride  of  mercury,  109-111 

Bladder  irrigation,  25 

Bleeding;  see  Hemorrhage 

Body  temperature,  1-3 

Boils,  96 

Boracic  acid,  103,  112 

Brushes,  65 

Burns,  94 


Carbolic  acid,   101 

poisoning  from,  51 
Carbon  monoxide,  poisoning  from,  52 
Carbuncle,  96 
Care  of  the  dead,  39 
Cataplasms;  see  Poultices 
Catheterization  and  bladder  irriga- 
tion, 25 

Caustic  alkali  poisoning,  51 
Changing  bed  linen,  14 
Chills,  47 

Chloral,  poisoning  from,  52 
Chlorinated  lime,  105 
Chlorine  poisoning,  49 
Coal  tar,  107 

poisoning  from,  52 
Cocain,  113 

poisoning  from,  52  * 

Common  emergencies,  45 
Complications,  surgical,  81 
Contusions,  90 
Copper  poisoning,  49 
Corrosive  poisons,  51 
Corrosive  sublimate,  101 
Croton  oil  poisoning,  49 
Creolin,  102 
Cystitis,  86 


Dead,  care  of  the,  39 
Diet,  32-34 

before  operations,  57 
Digitalis,  poisoning  from,  53 
Dishes  and  utensils,  68 
Disinfection,  63 
Douche,  preparation  for,  16 
Dressings,  66 
Drowning,  46 
Duties  of  staff,  62 

Emergencies,  common,  45 
Emetics,  48 
Enema,  nutrient,  29 
preparation  for,  16 
Epilepsy,  46 
Epistaxis,  98 
Examination,  full,  37 

Fainting,  45 

Feeding,  nasal,  28 

Foods;  see  Diet 

Formaldehyde,  solutions,  102,  108 

poisoning  from,  49 
Full  examination,  37 


Gloves,  65 
Glycerine,  69 
Gunshot  wounds,  92 

Hand  disinfection,  63 
Hematemesis,  98 
Hemoptysis,  98 
Hemorrhage,  83,  97-100 
Hydrocyanic  acid,  poisoning  from,  53 
Hypodermic  injections,  24 
Hypodermoclysis,  87 
Hysteria,  46 


Incised  wounds,  90 
Incompatibilities,  36 
Infection  of  wounds,  84,  93 
Infectious  cases,  general  care  of,  41 
Injections  hypodermic,  24 
Instruments  and  supply  room,  65 

sterilization  of,  68 
Intestinal  obstruction,  86 
Intravenous  saline  infusion,  88 
Iodine  poisoning,  49 
lodoform,  105 

gauze,  67 

poisoning  from,  53 
Irrigation  of  bladder,  25 
Irritant  poisons,  49 


INDEX 


Lacerated  wounds,  91 
Lav  age,  21 
Lead  poisoning,  50 
Lifting  the  patient,  15 
Lysol,   102 

Medicine,  administration  of,  35 
Mercury  poisoning,  50 
Methods  of  sterilization,  65 
Metric  system,  the,  106 
Mineral  acids,  poisoning  from,  51 
Mouth  washes,  47 

Nasal  douche,  23 

Nasal  feeding,  28 

Neurotic  poisons,  52-54 

Nicotine  poisoning,  53 

Normal  salt  solution,  69 

Nutrient  enema,  29 

Nux  vomica,  poisoning  from,  53 

Obstetrical  bed  making,  13 
Obstruction,  intestinal,  86 
Operations,  after-care  of,  77 

preparation  for,  56-60,  71 
Operating  room,  the,  60 
Opium  poisoning,  54 
Oxalic  acid,  103 

poisoning  from,  51 

Packing,  67 

Peritonitis,  85 

Peroxide  of  hydrogen,  104 

Phosphorus  poisoning,  50 

Pneumonia,  85 

Poisoned  wounds,  92 

Poisons,  48-54 

Potassium  permanganate,  103,  112 

Poultices,  31 

Preparation  of  patient,  56 
of  patients  room,  17,  55 
for  douche  and  enema,  16 


Proctoslysis,  88 
Ptomain  poisoning,  50 
Punctured  wounds,  91 
Pulse,  3-6 

Records,  bedside,  7-9 

operative,  70 
Respiration,  6 

Room,  preparation  of,  17,  55,  71,  64 
Rubber  gloves,  65 


Salt,  69,  103,  104,  112,  113 
Septicemia,  86 
Shock,  81-83 
Sick  room,  the,  17,  55 
Silver  poisoning,  50 
Sodium  carbonate,  105 
Sodium  bicarbonate,  104 
Solution,  69,  101-114 
Sordes  47 

Sterilization,  methods  of,  65 
Sterilizing  room,  64 
Surgical  bed  making,  12 

complications,  81 

room,  how  to  clean,  18 

numng,  55-90 

shock,  81-83 
Sutures,  66 


Technique  of  tables,  61 
Temperature;  see  Body  temperature 
Test  breakfast,  the,  23 


Ulcer?,  96 

Wheel  chairs,  16 
Wound  infection,  84 
Wounds,  90 

Zinc  poisoning,  50 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 
BERKELEY 

Return  to  desk  from  which  borrowed. 
This  book  is  DUE  on  the  last  date  stamped  below. 


13Aug'5gJi 
REC'D  LD 

OCT  19  1953 


DtC    81953LU 


DEC  1  5  1955  Lti 


LD  21-100m-9,'47(A5702sl6)476 


PEB 


AUG9    1961 


YC   M89& 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 


